Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral palsy, hypertension and heart disease. 
Treatment: 168 hours/week, 12 hours x 2 x 7 days - split shift: consumer direct, 1 client personal care aide (PCA). 
The insurer denied coverage for 168 hours/week, 12 hours x 2 x 7 days - split shift: consumer direct, 1 client personal care aide (PCA). 
The denial is upheld. 

This is an adult male with cerebral palsy, hypertension and heart disease. He lives alone in a 1-bedroom apartment. His sister provides informal care. The insurer partially denied coverage for 168 hours/week, 12 hours x 2 x 7 days - split shift: consumer direct, 1 client personal care aide (PCA), as not medically necessary. In a Final Adverse Determination letter, they stated the plan initially approved 29.75 hours/week, consumer direct, 1 client. The plan approval increased to 84 hours/week, consumer direct, 1 client. The patient is seeking 168 hours/week, 12 hours x 2 x 7 days - split shift: consumer direct, 1 client personal care aide (PCA). 

The patient's cognition is described as modified independent. He is able to make his needs known, able to dial 911 if needed and has a Personal Emergency Response System (PERS). He reportedly requires extensive to maximal assistance for performing much of his Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing, locomotion, toilet transfer and ambulation. Extensive assistance is reportedly needed for upper body dressing and toilet use. Limited assistance is reportedly needed for bed mobility and eating. The patient is reportedly infrequently incontinent of bladder and bowel. 

The patient's functional ability has modestly declined which supports the significant personal care aide (PCA) increase by the insurer from 29.75 hours/week, consumer direct, 1 client to 84 hours/week, consumer direct, 1 client. The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested 168 hours/week, 12 hours x 2 x 7 days - split shift: consumer direct, 1 client personal care aide (PCA). 

This physician would agree that the patient may benefit from additional monitoring, particularly due to his falls risk. However, safety monitoring under personal care aide (PCA) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. This physician would also agree that attention to the patient's functional needs can be appropriately provided and maintained by the recently approved increase personal care aide (PCA) 84 hours/week, consumer direct, 1 client. The patient also has the option of restructuring and flexibly using the 84 personal care aide (PCA) hours weekly (e.g., split 12-hour shift to morning and early evening shifts) to better maintain and meet his functional needs. 

From a physical medicine and rehabilitation perspective, 168 hours/week, 12 hours x 2 x 7 days - split shift; consumer direct, 1 client personal care aide (PCA) is 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 168 hours/week, 12 hours x 2 x 7 days - split shift; consumer direct, 1 client personal care aide (PCA) services is not substantiated.