Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure, Hypertension

Treatment: Personal care aide (PCA) live in, 7 days a week

The insurer denied coverage for personal care aide (PCA) live in, 7 days a week

The denial is upheld.

This is a patient with chronic medical problems including congestive heart failure, hypertension and pacemaker placement.  The patient lives alone in a private residence.  The patient is approved for personal care aide (PCA) 8 hours/day, 7 days/week.  The request is PCA (live-in) 7 days/week that was denied by the insurer, leading to an external review.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times."  The patient is reportedly total dependent for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient is also reportedly total dependent for bathing.  Maximal assistance is reportedly needed for lower body dressing, bed mobility, locomotion, toilet transfer/use and ambulation.   Extensive assistance is reportedly needed for upper body dressing and eating.  The patient is incontinent of bladder and infrequently incontinent of bowel.  The patient's ability to perform activities of daily living (ADL) and overall self-sufficiency have declined and deteriorated, respectively, over the prior 90 days.  

The letters from the patient's treating physicians describing their clinical condition and need for home care services were reviewed.   The associated treatment notes respectively were also reviewed and do not document any specific functional assessment.   

However, the patient has been a resident of a skilled nursing facility recently.  The skilled nursing facility therapy notes were submitted for review and demonstrate a higher level of function when compared to the UAS report.  According to the therapy notes, the patient was independent with bed mobility and required only supervision for transfer activities.  The patient was also able to ambulate approximately 200 feet with a 2-wheeled walker and supervision.  A similar level of functional ability was documented by the occupational therapist.  The patient was independent or supervision level for oral hygiene, toileting hygiene, toilet transfer and upper/lower body dressing.  

The reviewer would agree, the patient may benefit from additional monitoring for safety, particularly due to her diagnosed congestive heart failure and use of portable oxygen.  However, PCA service hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance; not primarily for safety monitoring.  Based on the documents reviewed, the patient's functional needs are appropriately provided by the approved PCA 8 hours/day, 7 days/week.  

The healthcare plan acted reasonably, with sound medical judgment and 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) live-in, 7 days a week 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 personal care aide (PCA) live in, 7 days a week is not substantiated.