Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: coronary artery disease, asthma and hypertension

Treatment: Personal Care Aide Services from 7 days per week two 12-hour Shifts, per day (or a Split Shift) 

The insurer denied coverage for Personal Care Aide Services from 7 days per week two 12-hour Shifts, per day (or a Split Shift) 

The denial is modified

 
This is an elderly female with chronic medical problems including coronary artery disease, asthma and hypertension.  She lives alone in a private residence.  The insurer reduced her personal care aide (PCA) services from 7 days per week (2) 12-hour Shifts, per day (or a Split Shift) to 7 days per week 8 hours per day (or 56 hours per week); leading to an external review.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as minimally impaired.  She is reportedly total dependent to maximal assistance for performing much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing, lower body dressing and toilet use.  Limited assistance is reportedly needed for upper body dressing, locomotion, toilet transfer and ambulation (uses a cane indoors and a walker outdoors). She is at the supervision level or independent for bed mobility and eating.  The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel.  There have been no reported falls over prior 90 days.  

The (undated) letter from the patient's treating nurse practitioner (NP) describing her clinical condition and reported need for continuing "2 split shifts of 12 hours of home care daily and nightly, 7 days per week to maintain her current health and prevent her illness from progressing" was reviewed.  The NP did not include any associated treatment notes to support his claim of the patient's reported functional incapacity.  The patient's cognitive and functional ability have actually improved when compared to the prior UAS reports; however, not to the level of decreasing care from 24 hours/day (split shift) to 56 hours/week.    

This physician would agree, the patient's clinical condition and functional deficits are not at a level and unpredictable as to require the PCA services  7 days per week two 12-hour Shifts, per day (or a Split Shift).  This physician would also agree that the patient may benefit from additional monitoring; particularly due to her reported cognitive decline and  falls risk.  However, safety monitoring under PCA services does not include monitoring an individual (For example (e.g.), with dementia) when no other Level I or Level II personal care services task is being provided.  Based on the documents reviewed, the patient's functional needs can be appropriately provided and maintained via PCA services 12 hours/day, 7 days/week, total 84 hours/week.  The patient also has the option of restructuring and flexibly using the 84 PCA hours weekly to better maintain and meet her 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 Services from 7 days per week two 12-hour Shifts,
per day (or a Split Shift) to 7 days per week 8 hours per day (or 56 hours per week) services is not substantiated. However, PCA services 7 days/week, 12 hours/day, total 84 hours/week is medically necessary.