Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, Chronic obstructive pulmonary disease, Cardiovascular disease

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, for a total of 84 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, for a total of 84 hours per week.

The denial is overturned. 

This is a male patient who has an extensive medical history associated with substantial functional impairment. He lives alone and receives personal care aide (PCA) services 6 hours per day, 42 hours per week. The patient requested increase of PCA services to 12 hours per day, 84 hours per week.

The Uniform Assessment System (UAS) report indicates the patient needs maximal assistance or total dependence for most Instrumental Activities of Daily Living (IADLs), except for managing finances (limited assistance) and phone use (setup help).  He needs maximal or extensive assistance for all Activities of Daily Living (ADLs), except eating (limited assistance).  The UAS describes some degree of impaired cognition. There is a diagnosis of dementia. It appears the patient has early stage dementia, and so it is less likely that the patient's cognitive impairment has a major effect on his ADL abilities at this time. However, memory impairment and poor judgment in certain situations can adversely affect his ability to safely perform ADLs. The UAS describes the patient's decision making for daily tasks as minimally impaired; in certain situations, decisions become poor/unsafe. Additionally, he has short term memory impairment.

Functional decline in older people is usually the result of cumulative and interactive effects of various medical conditions, and non-medical factors. The patient has multiple medical conditions and associated symptoms that most likely contribute to physical impairment and have a substantial effect on his daily function: osteoporosis; chronic obstructive pulmonary disease (COPD), and cardiovascular disease. The patient's medical conditions have a cumulative effect, resulting in significant pain, dyspnea and fatigue.  The physical work of performing daily activities with these symptoms is stressful. When a person experiences all these symptoms on a regular basis, the effort to perform most daily activities can become a burden.  The outcome is substantial loss of function and dependence on caregivers for daily activities.

Considering the patient's medical conditions and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day to provide assistance with daily activities, including ADLs that occur at various times throughout the day. Assistance is needed to ensure proper completion of daily activities and help decrease adverse health/safety events. Caregiver assistance can help relieve the physical burden associated with performing daily tasks. 

Considering the request for additional PCA services is for 12 hours per day, 84 hours per week, it is reasonable to conclude that there are no informal caregivers who can provide care for that amount of hours per week.  Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services.  When informal caregivers are unavailable for personal care assistance on a regular basis, then personal care services are indicated to provide necessary assistance with daily activities as needed throughout the day. The maximum amount of PCA services that can be approved from this review is limited by the number of hours requested; in this case, 84 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 the requested PCA Level 2: 12 hours per day, 7 days per week, for a total of 84 hours per week is overturned.  The medical necessity is substantiated.