Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer

Treatment: Home health care

Insurer Denial: coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days per week and consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week - a combined total of 168 hours per week (split shift)

Outcome:  Reversed
 

This is an elderly person with chronic medical problems including hypertension, heart failure and Parkinson's disease.  He also requires portable oxygen and receives hospice care.  The patient lives with his daughter, who along with his other daughters is supportive and involved in his care.  The insurer approved Personal Care Aide (PCA) level 2; 12 hours/day- 6 days/week; and consumer directed personal assistance program (CDPAP) 12 hours/day-1 day/week.  The insurer denied the requested for PCA Level 2: 12 hours per day - 7 days per week and CDPAP: 12 hours per day - 7 days per week - a combined total of 168 hours per week (split shift); leading to an external review.

According to the Uniform Assessment System (UAS) report dated 6/08/23, the patient's cognition is described as moderately impaired.  He reportedly requires maximal assistance to total dependence for performing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient is reportedly totally dependent for bathing, personal hygiene, dressing, eating, bed mobility, locomotion, toilet transfer and ambulation.  He is frequently incontinent of bladder and bowel.  There have been no reported falls over the prior 90 days.  

The patient's functional ability and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.   The patient's cognitive ability has not significantly changed when compared to the UAS report dated 02/25/22.  However, his functional ability has declined when compared to the UAS report dated 02/25/25.  The hospital discharge summary note was also reviewed.  The patient was admitted to the hospital, due to worsening shortness of breath.  He was treated with intravenous antibiotics for diagnosed pneumonia and discharged home with oral antibiotics.    

There is a letter from the doctor noting that the patient since his admission requires total care for all activities of daily living (ADLs) and IADLs. The patient is incontinent of bowel and bladder and becoming increasingly confused. In a letter, the doctor indicated he is bed bound at risk for pressure ulcers due to the incontinence needing every (q) 2 hour turning. The daughter in a note indicates he is showing skin redness and wakes up in middle of night. He has been in the same position for 12 hours. 

The patient's clinical condition and functional deficits are at a level and unpredictable as to require the requested PCA Level 2: 12 hours per day - 7 days per week and CDPAP: 12 hours per day - 7 days per week - a combined total of 168 hours per week (split shift).  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.