Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibromyalgia, Polyarticular osteoarthritis, Inflammatory arthritis, Cervical and lumbar degenerative disc disease.

Treatment: Personal Care Aide (PCA) Level 2 services, 8 hours per day, 5 day per week (total of 40 hours per week)..

The insurer denied coverage for Personal Care Aide (PCA) Level 2 services, 8 hours per day, 5 day per week (total of 40 hours per week).

The denial is upheld.

This is a female patient with a medical history of anxiety, right lower extremity (RLE) cellulitis, constipation, fibromyalgia, folate deficiency, irritable bowel syndrome, generalized osteoarthritis, abnormalities of gait/mobility, asthma, urinary incontinence, cervical myelopathy and radiculopathy, bilateral knee degenerative arthritis, left ankle degenerative arthritis and chronic low back pain. The patient receives Personal Care Aide (PCA) services 6 hours per day, 5 days per week (total of 30 hours per week). A request was made for an increase of PCA hours to 8 hours per day, 5 days per week (total of 40 hours per week) which was denied by the insurer. 

As per the Uniform Assessment System (UAS) report, the patient lives with her husband who provides assistance. The patient is dependent for shopping. The patient needs maximal assistance with meal preparation, ordinary housework; extensive assistance with managing finances, stairs, transportation, bathing and lower body dressing; limited assistance with walking and locomotion; supervision with managing medications and toilet transfers; setup help for personal hygiene, toilet use, upper body dressing and eating. The patient had pain rated 9 out of 10, dizziness, moderate fatigue and infrequent urinary incontinence. The patient had one fall in the past 30 days and was hospitalized for 4 days due to right lower extremity (RLE) cellulitis from a cat bite.  

The patient has severe fibromyalgia, polyarticular osteoarthritis, inflammatory arthritis, and cervical and lumbar degenerative disc disease. Her ability to ambulate and perform activities of daily living (ADLs) is affected. She has difficulty lifting more than 5 pounds and becomes fatigued with minimal exertion. The patient has pain, weakness and has fatigue with prolonged standing and walking. She can walk one block.  

Based the review of the medical record, there is no documentation that indicates the patient had a fundamental change in status. The patient needs setup help for dressing upper body and meals, and can perform bed mobility. Personal hygiene is with setup help and she ambulates with a walker. Documentation does not indicate what functional decline has occurred to support more PCA hours. 

PCA Level 2 services, 8 hours per day, 5 day per week (total of 40 hours per week) are not considered medically necessary for this patient. As noted above, there is insufficient documentation to support a change in this patient's clinical status that would require more hours of PCA services. 

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for PCA Level 2 services, 8 hours per day, 5 day per week (total of 40 hours per week) is upheld. The medical necessity is not substantiated.