Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthostatic hypotension, Parkinson's disease and cerebral vascular disease

Treatment: Personal care assistance (PCA) services, total of 84 hours per week

The insurer denied coverage for PCA services, total of 84 hours per week

The denial is upheld  

This is a patient with chronic medical problems including orthostatic hypotension, Parkinson's disease and cerebral vascular disease. The patient lives with the spouse who works outside the home Thursdays through Sundays. The request is for 12 hours per day, 7 days per week (84 hours per week), which is under review.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired. The patient reportedly requires maximal to extensive assistance for Activities of Daily Living (ADLs) tasks including meal preparation, ordinary housework and shopping. The patient also reportedly requires maximal assistance for lower body dressing. Extensive assistance is needed for bathing, personal hygiene, upper body dressing, locomotion, ambulation (indoors/outdoors with walker) and toilet transfer/use. The patient is independent with bed mobility and supervision for eating. The patient is frequently incontinent of bladder and incontinent of bowel.  

The patient's wife reportedly works outside of the home Thursdays through Sundays. The paid caregiver is a family friend. The patient can verbalize an emergency plan and can activate the Personal Emergency Response System (PERS) or call 911 during an emergency. The patient's clinical condition and functional ability are not at a level or unpredictable as to require the requested Personal Care Assistance Services (PCA) level 12 hours per day, 7 days a week, for a total of 84 hours per week. Based on the enclosed records reviewed, the patient's spouse is not present in the home Thursdays through Sundays as the spouse works outside the home. For the time the spouse is not present; PCA services 10 hours per day, 4 days per week (total of 40 hours per week) is clinically appropriate. However, the days the patient's spouse is present in the home, additional PCA services are not medically necessary. In addition, most of the instrumental activities of daily living (IADL) tasks (such as meal preparation, ordinary housework and shopping) are provided by the shared responsibility of the spouse. The spouse also manages the care, their finances and the medications. This physician would agree the patient may require additional monitoring; particularly due to the orthostasis and falls risk.  However, safety monitoring under Personal Care Services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   Based on the enclosed documents reviewed, attention to the patient's physical needs can be appropriately provided and maintained by PCA services 10 hours/day, 4 days/week, totaling 40 hours/week.  

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 services (PCA), total of 84 hours per week is not substantiated.