Appeal type: Medical necessity
Decision: Upheld

Diagnosis: heart failure, coronary artery disease and peripheral vascular disease

Treatment: Personal Care Assistance Services (PCS) 4 hours per day, 7 days per week, a total of 28 hours per week

The insurer denied coverage for Personal Care Assistance Services (PCS) 4 hours per day, 7 days per week, a total of 28 hours per week

The denial is upheld

 
This is an elderly female with chronic medical problems including heart failure, coronary artery disease and peripheral vascular disease.  She lives with her spouse, daughter and daughter's family.  The insurer approved 11 personal care assistance (PCA) service hours per week.  The patient requested an increase PCA Services to 4 hours per day, 7 days per week, for a total of 28 hours per week; leading to an external review.  

According to the Uniform Assessment System (UAS) report the patient's cognition is described as independent.  She is reportedly total dependent for completing much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires maximal assistance for lower body dressing, extensive assistance for bathing and limited assistance for upper body dressing.  She is otherwise at the supervision level or independent with personal hygiene, eating, bed mobility, toilet transfer/use, locomotion and ambulation.   The patient reports being infrequently incontinent of bladder and continent of bowel.   There has been no change in the patient's ability to perform activities of daily living, self-sufficiency or reported falls over the prior 90 days.  

The patient's medical condition and physical limitations are not at a level or unpredictable as to require PCA services 28 hours/week.  The letters from the patient's treating physicians respectively describing her clinical condition and request for additional PCA services were reviewed. An office visit note confirms the patient's normal cognitive ability and independent functional mobility.  The patient is described as healthy appearing, in no acute distress and "ambulating normally."  She has good judgement, normal mood/affect and normal recent and remote memory.

This physician would agree, the patient may benefit from additional monitoring for safety; particularly due to her reported general weakness, shortness of breath and falls risk.  However, PCA service hours are approved primarily to provide hands-on assistance for completion of IADL/ activities of daily living (ADL) tasks when no else is available to provide assistance; not primarily for safety monitoring.  Based on the records reviewed, the patient's health and safety are appropriately provided and maintained by the shared household responsibilities of the other adults living in the home and the approved 11 PCA service 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 4 hours per day, 7 days per week, a total of 28 hours per week services is not substantiated.