Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: kidney disease, hypertension and anemia

Treatment: for personal care assistance (PCA) services live-in per day, 7 days per week

The insurer denied coverage for for personal care assistance (PCA) services live-in per day, 7 days per week

The denial is modified
 

This is an advanced elderly patient with chronic medical problems including kidney disease, hypertension and anemia. She lives alone in a private residence. She was hospitalized due to rectal bleeding. The patient was transferred to a skilled nursing facility and eventually discharged home. The insurer approved personal care aide (PCA) services 7 hours/week, 7 days/week (total 49 hours/week) and the request is for PCA services live-in per day, 7 days per week.

The Uniform Assessment System (UAS) report dated 3/08/23 was reviewed. The patient's cognitive skills are described as minimally impaired. She is reportedly totally dependent to maximal assistance for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. Extensive assistance is reportedly needed for bathing, lower body dressing, locomotion, ambulation (uses a walker) and toilet transfer/use. Limited assistance is reportedly needed for personal hygiene, upper body dressing, and bed mobility. Supervision is reportedly needed for eating. She is frequently incontinent of bladder and occasionally incontinent of bowel. 

The letter from the patient's treating physician was reviewed and they note her medical history and indicate the patient "is no longer able to utilize a walker" and "needs full assistance for her aid to get out of bed to a sitting position and vise-versa." However, according to the physical therapy note the patient required only minimal assistance for bed mobility and transfers. She was also able to walk 100 feet with a walker. A subsequent physical therapy note indicates the patient requires only supervision to contact guard assistance for bed mobility and minimal assistance for transfers. She was able to ambulate 25 feet with a rolling walker. Treatment goals included independence with transfers and ambulate 140 feet with rolling walker. 

The patient's activities of daily living ADL status has declined over the prior 90 days. Her cognitive status and functional mobility have also declined when compared to the UAS report dated 6/03/22. There have been no reported falls over the prior 90 days. The patient's medical condition, cognitive deficits and physical limitations are not at the level or unpredictable as to require the requested PCA services to 7 days per week, 24 hours per day, live-in.  

Given the patient's reported cognitive deficits and general debility, she may benefit from additional safety monitoring. However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the records reviewed, a live-in PCA is not medically necessary. However, based on the clinical records which document a decline in her cognitive and functional status; increasing PCA to 10 hours/day is a more appropriate level of service to address the patient's functional needs.

Based on the above, the insurer's denial must be modified. 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 aide (PCA) services live-in per day, 7 days per week is not substantiated. However, increasing PCA services to 10 hours/day, seven days per week is medically necessary.