Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe COPD 

Treatment: Personal Care Aide (PCA) services, 7 days per week 24 hours per day live-in

The insurer denied coverage for Personal Care Aide (PCA) services, 7 days per week 24 hours per day live-in. The denial is upheld. 

This patient is a female lives alone and has been receiving personal care aide (PCA) services (most recently approved for 42 hours per week). The patient has severe COPD among several other chronic medical conditions. It is likely that several of her health problems contribute to her functional decline, but it appears her pulmonary disease currently has the most substantial adverse effect on her functional capacity. The patient has had two hospitalizations for decompensated COPD. Following the first hospitalization, she went to a rehab facility and was discharged home. Two weeks later she was admitted to the hospital again for respiratory failure. 
  
The patient's most recent UAS was done following return home after one hospitalization and rehab admission. The UAS indicates the patient needs substantial assistance for most IADLs and ADLs. She has dyspnea with usual daily activities. Her overall condition is declining, with poor appetite, significant weight loss, fatigue. The patient has a history anxiety, which is exacerbated when her breathing becomes more difficult. All of these symptoms are associated with end stage COPD. Following the most recent hospitalization for acute respiratory failure, she was transferred to SNF for rehab, with plan for home hospice. However, the patient had respiratory distress in the SNF and was transferred back to the hospital. The patient requested comfort care and was transferred to an inpatient hospice facility to manage her acute respiratory symptoms.

The patient has limited informal support at home. Her sister is involved in her care, but it is not known how much time and what type of assistance she can offer. If the patient returns home with hospice services, it is likely she will need a caregiver to help with medication management for symptom control. This cannot be provided by PCA services. At this point, the patient's current clinical status and discharge plan is not known. Considering the patient's functional status as described in the most recent UAS was significantly impaired, plus deconditioning from this recent acute respiratory episode, it is likely the patient will need substantial assistance with ADLs and IADLs. Considering the severity of her respiratory disease, the patient may have medical/nursing needs that cannot be managed by a personal care aide; and so other services and/or informal caregiver assistance will be necessary in addition to PCA services. At this time, there is insufficient information to determine an appropriate plan for PCA services. 
Due to lack of information of the patient's current medical status and discharge plan from inpatient hospice, PCA services cannot be determined at this time. When the patient is medically stable for discharge, updated information of the patient's medical, nursing and personal care needs will be necessary to make appropriate decisions regarding personal care services.

Based on the above, the medical necessity for Personal Care Aide (PCA) services, 7 days per week 24 hours per day live-in is not substantiated.  The insurer's denial is upheld.