Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lymphoma, Urinary Tract Infections

Treatment: Personal care aide (PCA) level 2: 12 hours/day, 7day/week

The insurer denied coverage for personal care aide (PCA) level 2: 12 hours/day, 7day/week.

The denial is upheld. 

This case involves an elderly patient seeking coverage for personal care aide (PCA) level 2: 12 hours/day, 7day/week.  The patient's medical history is significant for: precordial pain, shortness of breath, coronary atherosclerosis, essential hypertension benign, hypercholesterolemia, pneumonia, mild asthma, chronic obstructive pulmonary disease (COPD), hypertension, stented coronary artery, urinary tract infections, cervical lymphadenopathy, and Hodgkin lymphoma.

The most current Uniform Assessment System New York (UAS-NY) assessment noted the patient requires extensive assistance with bathing, walking, locomotion, toileting, transferring, upper body dressing and bed mobility. The patient requires limited assistance with eating. The patient is alert and oriented x (times) 3.  The patient requested 12 hours a day x 7days of PCA service because they have significant deterioration in functional and health status due to diagnosis of lymphoma, including joint pain, fatigue, weakness, and loss of fingers sensitivity because of immune treatment. The purpose of the aide is to assist with cooking and serving meals, assist with morning and evening personal hygiene, changing supplies, bathing, dressing, making the bed, escorting the patient outside for medical appointments and treatments. The patient lives alone in a 1-bedroom apartment that is located on the third floor of the building with elevator access, no steps at the entrance.  The patient's son is their healthcare proxy/emergency contact, and the patient's son and family are very supportive with the patient (calls daily, and visits once weekly).  The patient has a cane, walker, glucometer, shower chair, shower grab bar, personal emergency response system (PERS), labs, and incontinence supplies. The patient is forgetful at times, but expresses their ideas without difficulty and clearly understands conversations, and short term memory is intact. The PCA completes housekeeping, shopping, and meal preparation. This is to provide set up help and reminders with medications.  The member has occasional incontinence for bladder and is infrequently incontinent for bowel. Case Management (CM) discussed physical therapy (PT), occupational therapy (OT), and certified home health aides (CHHA) with the member.  Certified Home Health Agency (CHHA) services were approved and have begun.

In an appeal letter dated, the provider indicates the patient has multiple medical comorbidities. The patient resides alone and requires a walker to ambulate. The physician noted that the patient's functional mobility has declined over the past weeks. The provider stated the patient experiences confusion, and this makes it unsafe for the patient to stay alone and increases the risks for falls. 

The medical records submitted for review do not support the medical necessity of the frequency of care being requested. Based on the clinical documentation submitted, the current Personal Care Aide Services of 5 hours/day, 7 days/week for total of 35 hours/week are appropriate and safely meeting the patient's care needs. The assessment does support the determination of partial approval of personal care aide (PCA) for 35 hours/week that can be used flexibly to meet the patient's needs. As such, the denial of personal care aide (PCA) 12 hours/day x 7day/week is upheld as 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) level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week is not substantiated.