Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, Chronic Pain

Treatment: Personal Care Aide (PCA) Level 2: 9 hours per day, 7 days per week for a total of 63 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 9 hours per day, 7 days per week for a total of 63 hours per week.

The denial is upheld.

The patient is seeking coverage for Personal Care Aide (PCA) level 2: 9 hours per day, 7 days per week for a total of 63 hours per week.  The patient was diagnosed with atherosclerotic heart disease, osteoarthritis, and chronic pain.

The patient was seen for a routine reassessment. The expressed goal of care was to receive assistance with housework, shopping, cooking, bathing, and other activities of daily living.  The patient lived with a spouse.  The patient had modified independence with cognitive skills. There was some difficulty in new situations only.  There was no change in decision making as compared to 90 days prior. The patient was alert and oriented to place, time, and person. The patient reported that they were able to self-correct.  However, they were forgetful and would sometimes forget to take medications.  The patient could recall 2 out of 3 objects 5 minutes later.  The patient was able to make themselves understood and understood others. The patient had adequate hearing and minimal difficulty with vision. The patient required maximal assistance for meal preparation, total dependence for ordinary housework, extensive assistance for managing finances, supervision at managing medications, set up help only for phone use, extensive assistance with stairs, maximal assistance for shopping, extensive assistance for transportation, extensive assistance for bathing, limited assistance for personal hygiene, limited assistance for dressing of the upper body, and extensive assistance for dressing the lower body.  The patient required extensive assistance for toilet transfer and toilet use. The patient required limited assistance with bed mobility.  The patient ambulated with the use of an assistive device.  The patient reported that they required assistance with navigating stairs due to lower back and knee pain.  The reviewer observed the patient walking with the use of a cane with an unsteady gait.  The patient needed caregiver guidance with their arm.  

An increase in hours to 9 hours a day for 7 days a week was requested.  The family indicated that the patient had increased needs due to worsening pain and weakness.  There was reported worsening of cognitive function.  However, the assessment tools did not reflect a significant change in the patient's cognition and functional status that would support an increase in hours.  The patient's ability for dressing of the upper body, dressing of the lower body, personal hygiene, bed mobility, walking, locomotion, bathing, toilet transfer, toilet use, eating, meal preparation, medication management, and housework had remained the same from the prior assessment.  The patient had transportation to and from medical appointments as a provided plan benefit.  The patient had assistive devices within the home to help with completing activities of daily living.  The assessment did not reflect the family reported decline in the patient's capabilities.  Thus, the health care plan acted reasonably, with sound medical judgement, and in the best interest of the patient.  As such, the denial of coverage for Personal Care Aide (PCA) level 2: 9 hours per day, 7 days per week for a total of 63 hours per week is upheld as not medically necessary.

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 Aide (PCA) Level 2: 9 hours per day, 7 days per week for a total of 63 hours per week is not substantiated.