Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, coronary heart disease, hypertension, unspecified atrial fibrillation, gastroesophageal reflux disease without esophagitis

Treatment personal care assistance (PCA) services for a total of 85 hours per week

The insurer denied coverage for PCA services for a total of 85 hours per week

The denial is overturned

This is the case of a female with significant functional impairment and needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She lives alone and receives some informal support from family, but she relies mostly on personal care assistance (PCA) services to assist with daily activities. It was noted in the insurer's final denial letter that the family is requesting increase of PCA hours because the patient is very weak, unable to walk without help, and needs help with toileting. The patient is receiving PCA services 49 hours per week.

The New York State Department of Health's Uniform Assessment System (UAS-NY) provided. The functional status assessment indicates the patient needs maximal assistance for most IADLs; except managing medications (extensive assistance) and phone use (limited assistance). The patient needs extensive or maximal assistance for most ADLs; except eating (supervision) and bed mobility (setup help). 

The Uniform Assessment System (UAS) includes diagnosis of age-related cognitive decline. There is a spectrum of cognitive impairment from age related changes to mild cognitive impairment to dementia. The cause of the patient's cognitive decline is not clear, but the UAS describes significant cognitive impairment, which has an adverse effect on her ability to effectively and safely perform daily activities. Knee osteoarthritis is a common cause of impaired mobility in the elderly. As severity increases, it causes gait instability, often requiring some type of assistive device, and eventually may need physical assistance from a caregiver which appears to be the current situation for this patient. The patient needs assistance with toileting/incontinence care beyond 7 hours per day. It is reasonable to expect that the patient has toileting/incontinence care needs at various times during 17 hours of the day when the aide is not present. 

It is medically necessary to have caregiver assistance for all ADLs and IADLs throughout the day to help prevent adverse health and safety events, such as falls/injuries due to unassisted mobility; skin damage from inadequate toileting and incontinence care; nutritional decline, dehydration, and hypoglycemia due to inadequate food/fluid intake when she is alone. 

As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed, including ADLs that occur at unscheduled and recurring times throughout the day.

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

Personal Care Assistance services 85 hours per week are medically necessary.

The insurer's denial of coverage for the requested Personal Care Assistance (PCA) Services for a total of 85 hours per week is overturned. Medical