Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, coronary heart disease, congestive heart failure, and diabetes mellitus

Treatment: Increase in Personal Care Aide (PCA) services to 8 hours per day, 7 days a week for a total of 56 hours per week

The insurer denied coverage for increase in PCA services to 8 hours per day, 7 days a week for a total of 56 hours per week

The denial is overturned

This male has extensive medical history associated with functional impairment and needs help with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives with his wife, who is identified as the only informal helper. The patient has been receiving PCA services 6 hours per day, 7 days per week, total of 42 hours per week. The records indicate the patient's wife has difficulty providing care during non-PCA hours. The patient requested increase of PCA services to 56 hours per week (8 hours per day), which was denied. An external appeal was requested. 

The most recent Uniform Assessment System (UAS) report was reviewed. Functional status for IADLs indicates patient is totally dependent for ordinary housework; he needs maximal assistance for managing medications and finances, meal preparation, stairs, shopping, transportation; extensive assistance for phone use. For ADLs, the patient needs maximal assistance for toilet use; extensive assistance for bathing, personal hygiene, dressing upper and lower body, walking, locomotion, transfer toilet; limited assistance for bed mobility; supervision for eating. Comparison of recent UAS with prior UAS identifies functional decline for several ADLs.

Considering the patient's medical history and functional status as noted in the available records, it is apparent that the patient needs substantial assistance for most ADLs and IADLs. Therefore, it is medically necessary, and in the patient's best interest, to have a caregiver present throughout the day to assist with daily activities, including ADLs that occur at various unscheduled times throughout the day (e.g., transfers, walking, toileting, incontinence care). Without adequate assistance, the patient is at risk for adverse health and safety events, e.g., skin damage due to incontinence; falls/injury.

Considering the request for increase of PCA services is 56 hours per week, 8 hours per day, it is reasonable to conclude there are no informal helpers who can provide care during that period of time each day. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance for daily activities, including IADLs, routine ADLs, and ADLs that occur at unscheduled and recurring times throughout the day. Increase of PCA services to 8 hours per day will provide necessary help for the patient during daytime hours and decrease the wife's caregiving responsibilities.

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

The insurer's denial of coverage for increase in PCA services to 8 hours per day, 7 days a week for a total of 56 hours per week is overturned. Medical Necessity is substantiated.