Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease, heart failure, legal blindness, moderate conductive hearing loss and chronic kidney disease (CKD)

Treatment: personal care assistance (PCA) services 63 hours per week (9 hours per day, 7 days per week)

The insurer denied coverage for personal care assistance (PCA) services 63 hours per week (9 hours per day, 7 days per week)

The denial is upheld

 

This is elderly patient with a history of Alzheimer's disease, heart failure, legal blindness, moderate conductive hearing loss and chronic kidney disease (CKD). The patient's status remained the same per the doctor's note. In addition, the patient was reported to be walking normally with the use of a cane. The patient underwent ear wax removal and was unsuccessful due to inadequate home preparation. He denied any other acute problems. The patient was seen via telemedicine for a follow up for Covid result. The provider informed the patient that his Covid test was negative. It was noted that the patient had a positive QuantiFERON Gold plus test for tuberculosis exposure. The patient admitted to occasional cough and occasional night sweats. He was negative for sputum production and wheezing. The chest and lung exam were clear to auscultation, no wheezing and no dullness or hyper resonance. The patient's concentration and global orientation were impaired, and he was unaware of current events. The patient was seen for a follow up on laboratory results. The patient had proximal weakness and gait disturbances. His creatinine was 1.6, Vitamin D was low, and he was advised to hydrate well. A musculoskeletal assessment revealed no muscle atrophy or weakness, joints were intact, and the patient was noted to have both a normal gait, and also wobbly gait. Amlodipine and cholecalciferol were started.  

Based on the Department of Health Managed Long-Term Care (MLTC) Policy 16.07, "Safely monitoring, supervision, and cognitive prompting are not, by themselves, independent or "stand-alone" instrumental activities of daily living (IADLs), activities of daily living (ADLs), or tasks." It means that the plan is not to give more aide hours for supervision purposes alone. The presence of another person does not prevent falls. 

Based on the review of the information submitted, there is no new medical information or changes. The diagnoses are the same and the condition of hearing loss is not new and has been present. The patient can make decisions by himself and can direct his own care. He is alert to person and place, able to make needs known, and needs can be scheduled to be met during service hours. The patient can be safely left alone. The patient can use his Personal Emergency Response System and is able to dial phone numbers. Furthermore, the patient's occasional bladder incontinence is managed with the use of incontinence supplies. The patient is independent with eating after meal set up and is able to reheat his meals in the microwave. He needs little to no assistance with personal hygiene, walking, toilet transfers, bed mobility and eating. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care assistance (PCA) services 63 hours per week (9 hours per day, 7 days per week) is not substantiated.