Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Angina, gout, overactive bladder, peripheral vascular disease, osteoarthritis, diabetes, and incontinence
Treatment: Personal care aide (PCA) level 2, live-in per diem, 24 hours per day, 7 days per week

The insurer denied coverage for personal care aide (PCA) level 2, live-in per diem, 24 hours per day, 7 days per week.
The denial is overturned.

This patient has multiple medical conditions associated with substantial functional impairment and depends on caregiver assistance for all daily activities. The patient lives alone. Her family members provide some informal support, but the patient mostly relies on personal care services for assistance with daily activities. The patient has been receiving personal care aide (PCA) services 56 hours per week, 8 hours per day. Request was made to increase services to 24 hour live-in 7 days per week. 

The most recent Uniform Assessment System (UAS) functional status report for instrumental activities of daily living (IADLs), indicates patient is totally dependent or needs maximal assistance for all IADLs, except phone use (extensive assistance). For activities of daily living (ADLs), the patient needs maximal assistance for bathing, lower body dressing, walking/locomotion, transfer toilet; and extensive assistance for personal hygiene, upper body dressing, toilet use, bed mobility, eating. Compared to a UAS completed months prior, the patient's ability of walking/locomotion and toilet transfer have declined.

The records provided for review indicate patient has some degree of cognitive impairment. The UAS indicates patient has short term and procedural memory problem, oriented to self and place. She is forgetful and confused more often at the end of the day. The physician also reported patient's confusion increases at night. The physician reported patient had recent cerebrovascular accident (CVA). There is no other description of CVA in the records, but the physician reported patient deteriorated after the CVA. This raises the question of whether the patient's cognitive impairment could be due to cerebrovascular disease with further decline after recent CVA. It appears that cognitive impairment is a contributing factor to the patient's functional decline.

The UAS indicates the patient is dependent on caregivers for all toileting related tasks, including toilet transfer and toilet use. It is reported that she has frequent urinary incontinence. The two falls reported in the UAS occurred when patient was trying to get up from bed (she fell to floor when sitting on edge of bed), and the other fall occurred when using the toilet during the night (she fell off the toilet and could not get up until help arrived). Bathroom related falls are associated with increased risk of injury for older people. The plan of care needs to be modified to correct this situation.

MLTC (Managed Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. The patient's need for assistance with mobility and toileting/incontinence care at various unpredictable times of the day and night is not stand-alone safety monitoring. These care needs must be considered in the determination of the patient's personal care service hours. 

With live-in services, the patient will benefit from additional ADL assistance during the evening/night hours that is not available to her with her current services (PCA 8 hours per day). The live-in aide will be able to help identify the patient's evening and nighttime care needs. Re-assessment will determine whether the patient's care needs are sufficiently met with live-in services or if a different plan is needed.

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 personal care aide (PCA) level 2, live-in per diem, 24 hours per day- 7 days per week is overturned. Medical Necessity is substantiated.