Appeal type: Medical necessity
Decision: Upheld

Diagnosis: osteoarthritis, weakness, pain and fatigue 

Treatment: personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours

The insurer denied coverage for personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours

The denial is upheld. 

This is an elderly female requesting coverage for personal care aide (PCA) level 2: 8 hours per day - 7 days per week - for a total of 56 hours per week. 

In the uniform assessment the patient reported she needed help with cleaning, laundry, shopping, bathing, and cooking. She lives alone in a one-bedroom apartment in an elevator and wheelchair accessible building. The patient reported requiring hands-on assistance with most Activities of Daily Living/Instrumental Activities of Daily Living (ADLs/IADLs) except with phone usage, eating, and toilet use. She reported her ADL status has declined and deteriorated due to progression of her osteoarthritis, increased weakness, pain, fatigue, stiffness, and decreased range of movement (ROM). 

The provider reported that the patient suffers from impaired coordination, motor function, limited range of movement (ROM), reduced mobility, and is unable to walk independently without human assistance and use of a walker. They noted the patient suffers from hypertensive heart disease, sciatica, bilateral osteoarthritis of the knees, brachial plexus disorder, occipital neuralgia, spinal stenosis, and irritable bowel syndrome (IBS) with constipation. They also noted that the patient has urinary incontinence. The patient receives a personal emergency response system, medical supplies such as underpads, diapers, liners, and gloves for impaired continence patterns. She receives home care service to assist with ADL/IADLs 4 hours a day for a total of 28 hours per week. 

A Client Task Sheet for personal care worker/personal care aide (PCW/PCA) Level II was completed stating the patient needed 5.5 hours per day of personal care aide hours or a total of 38.5 hours per week. The documentation indicated that the patient's abilities to perform daily activities stayed the same for bathing, meal preparation, medication management, and housework and her abilities to perform daily activities declined for upper/lower body dressing, personal hygiene, bed mobility, walking, locomotion, toilet transfer, toilet use, and eating. They noted that the patient has shower chair, shower grab bar, walker, and incontinent supplies in the patient's home to help manage her needs.

Based on the records submitted, the patient reported a decline in her functional status; however, no additional documentation including physical exam findings and diagnostic testing to support the worsening of condition and lack of any improvement. There was also no history of emergency room (ER) visits or hospitalizations noted. The currently approved number of hours meets the patient's needs and can be used flexibly. 

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 additional personal care aide (PCA) services is not substantiated.