Appeal type: Medical necessity
Decision: Upheld

Diagnosis: axial neck pain, right cervical radiculopathy, status post cervical foraminotomy

Treatment: Personal Care Assistance services, 24 hours per day, 7 days per week (split shift)

The insurer denied coverage for Personal Care Assistance services, 24 hours per day, 7 days per week (split shift)

The denial is upheld

This is a patient who underwent cervical spine (C5-6, C6-7 posterior cervical foraminotomy) surgery. He is scheduled for C5-6, C6-7, anterior cervical discectomy and bilateral carpal tunnel release surgeries in the near future. He lives alone in a private home. The insurer approved personal care assistance (PCA) 36 hours/week, and the request is for PCA services 24 hours/day, 7 days/week (split shift), which is under review.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Independent."  He requires extensive assistance for bathing and lower body dressing. He is otherwise independent for personal hygiene, upper body dressing, bed mobility, locomotion, ambulation, eating and toilet transfer/use. He is continent of bowel and bladder.  The patient's clinical condition with intact cognitive status and independence for much of his activities of daily living tasks are not at the level or unpredictable as to require the require Personal Care Assistance (PCA) services 24 hours per day, 7 days per week (split shift).  

The requested Personal Care Assistance (PCA) services 24 hours per day, 7 days per week (split shift) is for the anticipated post-operative recovery from a scheduled cervical spine and bilateral carpal tunnel surgeries in the near future. The patient was seen by his treating surgeon, who noted the prior cervical spine surgery. The patient reportedly did well initially. However, he is now "a good candidate for a 2-level anterior cervical discectomy and fusion as well as a bilateral carpal tunnel release". On physical examination, the physician documented "all muscle groups within normal limits of strength and tone bilaterally." Gait was described as "normal."   In a letter the physician again noted the scheduled cervical spine and bilateral carpal tunnel surgeries scheduled in the near future, reportedly rendering the patient "impaired for some time while healing and he will be under a restriction to lift a certain amount of weight postoperatively.  

Post-surgical rehabilitation is best provided at an acute rehabilitation facility or subacute rehabilitation facility; skilled nursing facility and not at home with only 24 hours/day PCA services. In addition, the request for 24-hour PCA services is premature. The more appropriate assessment of his functional ability with regard to PCA services is best addressed after the scheduled surgeries and just prior to discharge home from an acute rehabilitation facility or skilled nursing facility. The need for skilled home nursing and therapy services in addition to PCA services can also be addressed at that time.  

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, 24 hours per day, 7 days per week (live-in or split shift) is not substantiated.