Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hypertension, atrial fibrillation and Alzheimer's disease. 
Treatment: Personal Care Aide (PCA) Live in Per Diem, 7 days per week. 
The insurer denied coverage for Personal Care Aide (PCA) Live in Per Diem, 7 days per week.  
The denial is modified. 

This is an elderly adult with chronic medical problems including hypertension, atrial fibrillation, and Alzheimer's disease. The patient lives alone in a 4-bedroom private residence. However, the family reportedly "Pays for member to have live-in Personal Care Aide (PCA) services to ensure member's safety." The insurer approved PCA level 2; 5.5 hours/day- 7 days/week and request is for PCA Live in Per Diem, 7 days per week; leading to an external review. 

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as moderately impaired. The patient reportedly requires maximal assistance to total dependence for completing much of their Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient requires extensive assistance with bathing, personal hygiene, dressing, locomotion, toilet transfer and ambulation. However, "PCA reports member now wandering at night thought out the home, will get through draws and reorganize things in home. PCA reports member will wander out onto deck and check to see if doors are locked, garage door is closed and lights are off." Limited assistance is reportedly needed for bed mobility and toilet use. The patient reportedly requires supervision for eating. The patient is reportedly occasionally incontinent of bladder and bowel. The patient's ability to perform activities of daily living and self-sufficiency have declined and deteriorated, respectively, over the prior 90 days. The patient's cognitive and functional ability have also declined when compared to the UAS report; particularly for dressing, personal hygiene, and toilet use. There has been no reported falls over the prior 90 days. The additional records indicate the patient has subsequently fallen. 

Based on the enclosed clinical documents, the patient does not have a medical condition, functional incapacity or level of care that requires Personal Care Aide (PCA) Live in Per Diem, 7 days per week. The letter, from the patient's treating physician, describing her clinical condition, and recommended "24-hour live-in care assistance" was reviewed. The patient was described as "Pleasantly confused. Oriented to person and place most of the time." Gait was described as "unsteady." 

This physician would agree that the patient may benefit from additional monitoring; particularly due to her cognitive decline, wandering and falls risk. However, safety monitoring under personal care services (PCS) does not include monitoring an individual (e.g., with dementia, falls risk, general weakness) when no other Level I or Level II personal care services task is being provided. This physician would also agree that the patient's functional ability has declined, her functional deficits are substantial and supports a more significant increase in PCA. Based on the documents reviewed, the patient's functional and home care needs are more appropriately provided and maintained by increasing PCA to 12 hours per day, 7 days per week (total 84 hours/week). 

From a physical medicine and rehabilitation perspective, increasing PCA services for a total amount of Live in Per Diem, 7 days per week is not medically necessary. However, increasing PCA services to 12 hours/day, 7 days/week is medically necessary. 

Based on the above, the insurer's denial is modified. The health care plan did not act reasonably in part and with sound medical judgment and in the best interest of the patient. The medical necessity for increase Personal Care Aide (PCA) services for a total amount of Live in Per Diem, 7 days per week is not substantiated. However, increasing PCA services to 12 hours/day, 7 days/week is medically necessary.