Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease, Chronic Obstructive Pulmonary Disease

Treatment: Personal Care Aide (PCA) services, Split shift, 24 hours per day, 7 days per week

The insurer denied coverage for Personal Care Aide (PCA) services, Split shift, 24 hours per day, 7 days per week

The denial is overturned

This is a patient with chronic medical problems including Alzheimer's disease, hypertension and chronic obstructive pulmonary disease (COPD). The patient lives in a 1-bedroom apartment with live-in Personal Care Aide (PCA) services.  A request for PCA services, Split shift, 24 hours per day, 7 days per week was denied by the insurer, leading to an external review.  

The Uniform Assessment System (UAS) report was reviewed.  The patient had been recently hospitalized for treatment of pneumonia and urinary tract infection.  The patient's cognition is "minimally impaired."  The patient is reported as totally dependent for much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient is also reportedly totally dependent for bathing and lower body dressing.  Maximal assistance is reportedly needed for bed mobility and toilet use.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing and eating.  The patient is reportedly bed bound with a hospital bed and gel overlay mattress.  The patient reportedly requires 2-person assistance (personal care worker and daughter) for bed mobility.  The patient is reportedly frequently incontinent of bowel and bladder.  

The patient's functional ability and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.  The patient also reportedly fell on 1 occasion over the past 30 days.  The letter from the patient's treating physician describing the patient's reported deteriorating condition and need for 24-hour PCA services (split shift) was reviewed.  The discharge summary from the patient's recent hospitalization (aspiration pneumonia and urinary tract infection) was also reviewed.  The summary also documents the patient's need for continuous portable oxygen.  

The patient's functional impairments are at a level or unpredictable as to require PCA services 24 hours/day (split shift).  Of particular concern is the patient's severely limited mobility, risk of pressure ulcers, infection (including recurrent aspiration pneumonia) and falls.  The patient requires routine repositioning in bed at least every 2-3 hours to decrease risk of ulcers, falls and infection.  Based on the clinical records, a live-in PCA is unlikely capable of obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift.  This physician would agree that attention to the patient's functional needs are more appropriately provided and maintained by the requested PCA services 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).   

From a physical medicine and rehabilitation perspective, Personal Care Aide (PCA) services, Split shift, 24 hours per day, 7 days per week is medically necessary.    

Based on the above, the insurer's denial must be reversed. 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 services, Split shift, 24 hours per day, 7 days per week is substantiated.