Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: coronary artery disease, hypertension, diabetes mellitus, status post left ankle fracture, hyperlipidemia, osteoarthritis, gastroesophageal reflux disease, insomnia, and severe depression

Treatment: Personal Care Aide (PCA) Level 2; 12 hours per day, 7 days per week, 12 hours per day, 7 days per week - a total of 168 hours per week (split shift)

The insurer denied coverage for Personal Care Aide (PCA) Level 2; 12 hours per day, 7 days per week, 12 hours per day, 7 days per week - a total of 168 hours per week (split shift) 

The denial is modified

 
The patient is an elderly adult seeking coverage for Personal Care Aide (PCA) level 2; 12 hours per day, 7 days per week, 12 hours per day, 7 days per week - total of 168 hours per week (split shift).  The patient is diagnosed with coronary artery disease, hypertension, diabetes mellitus, status post left ankle fracture, hyperlipidemia, osteoarthritis, gastroesophageal reflux disease, insomnia, and severe depression.

The patient was totally dependent for meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, bathing, dressing of the lower body, walking, and for locomotion.  The patient required maximal assistance with phone use, personal hygiene, dressing of the upper body, toilet use, bed mobility, and eating.  The patient utilized a wheelchair for ambulation.  The patient's health conditions caused pain, confusion, weakness, and limited range of motion.  The patient's daughter reported that the patient had a deterioration of self-sufficiency.  The patient's daughter reported that the patient was unable to stand, walk, pour water for themselves, and transfer themselves to the commode.  The patient was blind, had stomach pain, constipation, dizziness, and hallucinations.  The patient needed significant weightbearing assistance when adjusting clothing.  The patient was frequently incontinent of bladder and was continent of bowel.  

The provider stated that the patient's medical condition had deteriorated severely.  The patient was completely homebound.  The patient had been taken multiple times to the emergency department.  The patient's conditions were chronic and irreversible.  The prognosis for improvement was poor.  The patient had worsening ambulation abilities leading to falls.  The patient lived alone and had no formal or informal support to provide assistance.  The provider felt that the patient required split shift 168 hours of personal assistance services per week to assist with activities of daily living (ADL) and instrumental activities of daily living (IADL).  Activities included ambulating, using wheelchair, transferring, toileting, bathing, meal preparation, personal hygiene, medication reminders.  The patient needed assistance with turning and positioning every 2 hours during the night.  

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Personal Care Aide (PCA) Level 2; 12 hours per day, 7 days per week, 12 hours per day, 7 days per week - a total of 168 hours per week (split shift) services is not substantiated. However, 16 hours per day for 7 days per week for a total of 112 hours of personal assistance services per week is necessary.