Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, chronic pain, osteoarthritis, right hip replacement, heart failure, coronary artery disease with angina, ventricular arrhythmia, (status post) s/p automatic implantable cardioverter defibrillator (AICD) placement
Treatment: PCA services 84 hours per week
The insurer denied coverage for: PCA services 84 hours per week
The denial is: Overturned
This adult patient has functional impairment associated with several medical conditions and needs help with all activities of daily living (ADL's). The patient lives alone. As per Uniform Assessments for New York (UAS), the patient's daughter is the only informal helper. The patient primarily depends on personal care aide (PCA) services to assist with ADL's and independent activities of daily living (IADL's); the patient currently receives personal care aide (PCA) services 49 hours per week, 7 hours per day, 7 days per week. The patient requested PCA services 84 hours per week, 12 hours per day, 7 days per week. 

The most recent UAS provided for review includes functional status for IADL's as follows: Ordinary housework: total dependence; Meal preparation, managing medications, shopping, stairs, transportation: maximal assistance; Managing finances: extensive assistance; Phone use: limited assistance. For ADL's: Bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use: maximal assistance; Personal hygiene, dressing upper body, bed mobility, eating: extensive assistance.

The letter from the (Doctor of Nursing practice) DNP indicates the patient has dementia. Decision making for daily tasks is reported as minimally impaired; in specific situations, decisions become poor or unsafe; cues/supervision needed. The patient was oriented x 3; forgetful with short term memory problem. It was noted that the patient's mental function varies over the course of the day. Communication was described as difficulty finding words/finishing thoughts, but with time, little or no prompting is needed; The patient misses some intent of message but understands most of the conversation. No behavioral problems noted. 

The patient has physical impairments that significantly limit the patient's ability to perform various independent activities of daily living (IADL) tasks but it is likely that the patient's cognitive impairment also adversely affects some IADL's. Decline of activity of daily living (ADL) skills due to cognitive impairment does not usually occur until later stages of dementia. It is likely that the patient's physical impairments are the primary cause of their need for weight-bearing assistance with all ADL's. However, memory loss and impaired ability to make safe decisions increases risk of falls and household accidents when performing ADL's and IADL's. The records indicate the patient has chronic pain, which appears to be a significant cause physical limitations for daily activities. 

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance for daily activities, including ADL's that occur at unscheduled/recurring times of the day.
The patient will benefit from PCA services 12 hours per day to assist with all daily activities from morning until evening, when she has the most frequent need for assistance with ADL's and IADL's.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care aide (PCA) level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week is substantiated.