Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, rheumatoid arthritis, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure

Treatment: Personal Care Aide (PCA) hours, 7 days per week, 8 hours per day (56 total hours)

The insurer denied coverage for Personal Care Aide (PCA) hours, 7 days per week, 8 hours per day (56 total hours).

The denial is overturned. 

This is a female with a medical history of pulmonary sarcoidosis lung, adenocarcinoma lung, pulmonary nodule, chronic obstructive pulmonary disease, hypothyroidism, hyperparathyroidism, congestive heart failure, coronary artery disease, hypertension, thoracoabdominal aneurysm, osteoporosis, chronic renal failure, Hashimoto's thyroiditis, rheumatoid arthritis (RA), gait dysfunction, and depression. The patient has been receiving Personal Care Aide (PCA) services 42 hours per week. The patient and her physician identified the patient's need for more assistance and requested an increase of PCA services to 8 hours per day, 7 days per week (56 hours per week), which was denied.  

The patient has several medical conditions and symptoms that appear to cause substantial limitations to her ability for daily physical function: arthritis/chronic pain; dyspnea/pulmonary and cardiac disease; and fatigue. The patient experiences the combined effects of pain, dyspnea and fatigue on a regular basis. These symptoms increase the burden of performing mobility-related activities, which includes most activities of daily living (ADLs) and instrumental activities of daily living (IADLs); resulting in substantial loss of function and increasing dependence on caregivers for daily activities. The Uniform Assessment System (UAS) report, functional status assessment indicates the patient needs total dependence or maximal assistance for household related tasks and shopping; and limited assistance for finances and medications. For ADLs, the patient needs extensive assistance for bathing and dressing; and limited assistance for walking, transfer toilet and toilet use. She needs setup help with personal hygiene, eating, and bed mobility. The patient's cognitive status as described in the UAS indicates no significant memory impairment; she can make decisions for tasks of daily life, with some difficulty only in new situations. 

Considering the patient's medical history and associated symptoms limiting her physical functional ability, it is medically necessary and in the patient's best interest to have a caregiver present to assist with daily activities during hours of the day when the patient is most active. The information about informal caregivers in the UAS report does not clearly identify someone who can provide ADL assistance on a regular basis. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. Considering the patient is requesting PCA services 8 hours per day, it is reasonable to conclude that she does not have informal caregivers who can provide the care she needs for this time period each day. Without informal caregivers who can provide support with daily activities on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed, including assistance with ADLs that occur at various and unscheduled times throughout the day. It is not clear whether 8 hours of PCA services are sufficient to assist with all the patient's daily care needs. The maximum number of hours that can be approved from this review is limited by the amount of hours requested, i.e. 8 hours per day, 56 hours per week.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for PCA hours, 7 days per week, 8 hours per day (56 total hours) is overturned. The medical necessity is substantiated.