Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia, Depression

Treatment: personal care aide (PCA) level 2: 8 hours per day - 7 days per week - for a total of 56 hours per week

The insurer denied coverage for personal care aide (PCA) level 2: 8 hours per day - 7 days per week - for a total of 56 hours per week

The denial is overturned

This patient has experienced functional decline associated with various medical conditions and needs help with all daily activities. The patient lives alone. Family provides informal help (limited due to location; work schedule). The patient primarily relies on personal care aide (PCA) services to assist with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient receives PCA services 30.5 hours per week (4 or 4.5 hours per day). The patient (via designee) requested PCA services 56 hours per week, which was denied. External appeal was requested.

The most recent Uniform Assessment System (UAS) provided for review notes the functional status report for IADLs indicates the patient was totally dependent for ordinary housework; the patient needed maximal assistance for meal preparation, managing finances, shopping; extensive assistance for managing medications, phone use, transportation, stairs. For ADLs, the patient needed extensive assistance for bathing, personal hygiene, dressing upper and lower body, walking, locomotion, transfer toilet, toilet use, eating, bed mobility.

The records indicate the patient has a history several psychiatric conditions. The psychiatrist's reports diagnoses of schizophrenia and depression; treatment includes Lybalvi (olanzapine and samidorphan). The letter from the primary care physician (PCP) includes additional diagnoses of anxiety and somatoform disorder; medications include olanzapine and escitalopram. 

The psychiatrist's letter mostly discusses the patient's need for assistance with activities of daily living, but no specific details of the patient's psychiatric status.  The Primary Care Provider (PCP) letter includes symptoms described by the patient and family including poor concentration and memory; episodes of confusion, disorientation. The PCP reported the patient has episodes of abdominal pain associated with somatoform disorder (admitted to hospital several times), but no further details are noted. The UAS reports repetitive health complaints, unrealistic fears, anxiety, depressed mood, reduced social interactions. It was reported patient stopped going to social day care due to anxiety and depression. It was noted that the patient often has physical complaints, but no physical cause(s) have been found. However, the UAS reports the patient was admitted to the hospital due to abdominal pain and was treated for gastrointestinal (GI) hemorrhage with melena (no hospital records are available). 

The patient's son reported that family is unable to provide the patient with informal help for daily activities on a regular basis. The patient (via designee) requested PCA services 56 hours per week, and so it is reasonable to conclude there are no informal helpers who can provide care for this amount of time per week. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal helpers are unable to assist with necessary care on a consistent basis, then personal care services are indicated to assist with ADLs and IADLs when needed throughout the day. 

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: 8 hours per day - 7 days per week - for a total of 56 hours per week is substantiated.