Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, kidney disease and hypothyroid

Treatment: Personal care assistance (PCA) services, 7 days per week, 24 hours per day (split shift), a total of 168 hours per week

The insurer denied coverage for PCA services, 7 days per week, 24 hours per day (split shift), a total of 168 hours per week

The denial is overturned

This is an adult female with multiple medical problems including congestive heart failure, kidney disease and hypothyroid. She lives alone in a private residence. The insurer approved personal care assistance (PCA) services, 24 hour live in services 7 days per week and the request is for PCA services 7 days per week, 24 hours per day (split shift), for a total of 168 hours per week

According to the recent Uniform Assessment System (UAS) report, the patient's cognition is described as minimally impaired; however, she has "poor" ability to call 911 in an emergency or use a Personal Emergency Response System (PERS). She reportedly requires maximal assistance for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient also reportedly requires maximal assistance for bathing and lower body dressing. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, toilet transfer/use, locomotion and ambulation. Limited assistance is reportedly needed for bed mobility and eating. The patient is frequently incontinent bladder and of bowel.  

The patient's clinical condition and functional deficits are at a level and unpredictable as to require the increasing PCA services 7 days per week, 24 hours per day (split shift). This physician was also persuaded by the letter from her treating physician documenting the patient's clinical condition, multiple impairments and rapidly progressive functional decline. She requires routine repositioning in bed at least every 2 hours and has developed a pressure ulcer over her left buttocks. According to the UAS report, "repositioning every 2 hours has been reinforced with PCA." The patient also requires portable oxygen due to underlying chronic obstructive pulmonary disease (COPD) and continuous positive airway pressure (CPAP) at night. Based on the clinical records, a live-in PCA is unlikely capable of consistently obtaining approximately 5 hours of uninterrupted sleep over the course of a 24 hour shift. This physician would also agree that attention to the patient's functional needs are more appropriately provided and maintained by increasing PCA services 7 days per week, 24 hours per day (split shift), for a total of 168 hours per week.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, PCA services 7 days per week, 24 hours per day (split shift), for a total of 168 hours per week are medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care assistance (PCA) services, 7 days per week, 24 hours per day (split shift), a total of 168 hours per week is substantiated.