Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sciatica, fibromyalgia, neuropathic pain

Treatment: Personal Care Aide (PCA), level ll (90) hours weekly

The insurer denied coverage for Personal Care Aide (PCA), level ll (90) hours weekly. The denial reversed.

This patient is a female who has extensive medical history, with several medical conditions contributing to functional decline. The patient had previously been approved for and was receiving 90 hours per week of personal care aide (PCA) services. In the early-2019 assessment the patient met criteria for PCA services 13 hours per week; but 90 hours was approved by mistake. After the19 assessment, it was determined that the patient needs 19 hours PCA services per week. However, in order to ensure a safe transition, the insurer approved 50 hours PCA services per week. The patient and her physician feel this is not adequate. An external appeal was requested.

The late-2019 UAS indicates the patient needs substantial assistance for all household chores and outside activities (shopping, transportation). Regarding ADLs, extensive assistance is noted for bathing and dressing with all other ADLs noted as independent (including walking, toileting). The UAS notes that patient was observed walking independently. However, other notes include: gait is very unsteady; shortness of breath when walking; timed 4 meter walk (19) seconds indicates slow gait speed; difficulty moving to standing position unassisted (noted as daily); difficulty turning around when standing (noted as daily); multiple falls in past 30 days (patient reported "too many falls to count", "my legs just give out", "sciatica pain runs down my leg").  

Considering all aspects of the patient's health, associated symptoms and functional limitations, it appears that the patient has considerable disability. She is a relatively young woman, and efforts to improve various aspects of her health and functional capacity should continue to be pursued. However, at this point, it appears that her functional capacity is significantly limited. In fact, when comparing the UAS reports from late-2019 and early-2019 documentation indicates that the patient's ambulation was better earlier in the year.

Due the chronic nature of the patient's medical conditions, it is unlikely that all risk factors for falls can be eliminated. Various treatments (such as PT, weight loss, successful smoking cessation) can help; but at this point it is necessary to address the patient's needs based on her current status. The assistance provided by PCA services is not safety supervision alone. The patient has substantial physical limitations that require caregiver assistance/supervision for various mobility related ADLs throughout the day. At the present time based on the available information, it is medically necessary for the patient to have a caregiver present to assist/supervise with various activities, including all mobility related ADLs. The patient has no informal caregivers. In the absence of informal caregivers, then it is medically necessary for care to be provided by PCA services.

Personal care aide services, level II, 90 hours per week are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage continuation of Personal Care Aide (PCA), level ll (90) hours weekly is reversed.  The medical necessity is substantiated.