Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hereditary Spastic Paraplegia. 
Treatment: Personal care aide (PCA) services 7 days per day x 24 hours, split shifts, 168 hours per week. 
The insurer denied coverage for personal care aide (PCA) services 7 days per day x 24 hours, split shifts, 168 hours per week. 
The denial is upheld. 

This is a patient with hereditary spastic paraplegia (HSP). The patient lives with their spouse in a private residence. However, the patient was reportedly hospitalized with no discharge date in place. The insurer approved PCA services, 43 hours per week and the request is for PCA services 7 days per day x 24 hours, split shifts, 168 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as modified independent. The patient reportedly is total dependent to maximal assistance for performing much of their Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires extensive assistance for bathing and lower body dressing. Limited assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility, locomotion, toilet transfer/use and ambulation. The patient is independent for eating. The patient reports being occasionally incontinent bladder and continent of bowel. 

The letters from the patient's providers were reviewed, describing the patient's clinical condition and need for personal care aide services. One letter did provide more information regarding the patient's daily needs. Regarding the period from 11PM to 9AM, notes need for monitoring for potential falls/accidents and catheter related issues but provides no details regarding actual events. Also, the daytime listings do not support the requested hours. For example- the time from 1:30P to 5:30 PM is for getting dressed and ready for daily appointments that may arise. No frequency is provided to support these hours.  In addition, the treating physicians do not include the treatment notes, which should include a clinical assessment regarding the patient's reported progressive functional decline. The patient's functional ability has declined when compared to the UAS report and supports the insurer increasing the 31 PCA hours/week to 43 PCA hours/week.  However, the patient's clinical condition and functional deficits are not at a level and unpredictable as to require the increasing PCA services 7 days per week, 24 hours per day (split shift). The patient was reportedly admitted to the hospital; however, the hospital clinical records were not submitted for review or more recent clinical assessment. Also, as noted in Up to Date "The rate of progression and severity of different types of HSP is highly variable among and even within specific genetic types. Several patterns of progression have been described: A relatively nonprogressive course; Progressive worsening that stabilizes over time; or Inexorable decline. 

The healthcare plan acted reasonably, with sound medical judgment and 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, personal care aide (PCA) services 7 days per day x 24 hours, split shifts, 168 hours per week are 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) services 7 days per day x 24 hours, split shifts, 168 hours per week is not substantiated.