Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary heart disease, hypertension, hyperlipidemia, asthma, and dementia

Treatment: Personal care aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week

The insurer denied coverage for PCA level 2: 12 hours per day- 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week

The denial is upheld

This is a patient with a history of coronary heart disease, hypertension, hyperlipidemia, asthma, and dementia. Per the recent Uniform Assessment Systems- New York (UAS-NY) report, the patient lives alone in a 2-bedroom apartment with 10 stairs. She is alert and oriented x 1. She needs reminders to complete daily tasks. The patient requires total dependence with meal preparation and ordinary housework. She requires maximal assistance with managing medications. She is frequently incontinent of urine. There were no falls within the last 90 days. There is concern for safety due to cognitive deficits. Based on the medical data reviewed, the number of hours previously approved appear sufficient to meet the participant's mobility and activities of daily living (ADL's) needs. There is a lack of significant objective deficit, sufficient to warrant an increase in PCA hours per week at this time. As such, this request is not medically necessary.

Luz, C. C., Hanson, K. V., Hao, Y., & Spurgeon, E. (2018), "Further, PCA training is highly valued by clients who clearly believe it contributes to both physical and emotional health and that insufficient training results in negative consequences. In summary, the wide range of skills required for PCAs to provide high-quality, person-centered care delivered with respect and dignity is critical for older disabled or frail adults staying safely in their own homes. Attaining this level of skill requires comprehensive training."

Guo, H.J. and Sapra, A. (2022), "Instrumental activities of daily living (IADL's) are those activities that allow an individual to live independently in a community. Although not necessary for functional living, the ability to perform IADLs can significantly improve the quality of life. The major domains of IADLs include cooking, cleaning, transportation, laundry, and managing finances. Occupational therapists commonly assess IADLs in the setting of rehab to determine the level of an individual's need for assistance and cognitive function. IADLs are commonly confused with basic ADL's. The major domains of ADLs are feeding, dressing, bathing, and walking. In contrast with IADLs, ADLs are necessary for basic functional living. Deficits in performing ADLs may indicate the need for home healthcare or placement in a skilled nursing facility."    

The requested PCA level 2: 12 hours per day 7 days per week; 12 hours per day 7 days per week (split shift) a total of 168 hours per week is not considered medically necessary for this patient as this request is excessive given the individual is ambulatory and mainly needs household cleaning, chores, and medication management among other IADLs.                     

The health plan acted reasonably with sound medical judgment in the best interest of the patient.  

The insurer's denial of coverage for personal care aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week is upheld. Medical Necessity is not substantiated.