Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis, Back Pain with Compression Fractures

Treatment: Home Care/Personal Care Level 2, Personal Care services, increase to 24 hours per day (split shift)

The insurer denied coverage for home Care/Personal Care Level 2, Personal Care services, increase to 24 hours per day (split shift)

The denial is upheld

This is a patient with chronic medical problems including hypertension, osteoporosis and back pain with history of compression fractures. The patient lives with their spouse in a private residence.  The insurer approved personal care aide (PCA) Home Care/Personal Care Level 2, Personal Care services,  24 hours/day (live-in).  The insurer denied the request for PCA Home Care/Personal Care Level 2, Personal Care services, 24 hours per day (split shift), leading to an external review.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as moderately impaired.  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 reportedly requires maximal assistance for bathing, lower body dressing and toilet use.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, locomotion, toilet transfer and ambulation. The patient is at the supervision level for bed mobility and eating.  The patient reports being frequently incontinent of bladder and continent of bowel.  There has been no change in the patient functional ability, self-sufficiency or reported falls over the prior 90 days. The patient's cognitive ability has declined when compared to the prior UAS.  However, the patient's ability to perform their  activities of daily living (ADLs) is much the same, if not slightly improved.  

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require PCA services 7 days per week, 24 hours per day (split shift).  The letter from the patient's treating physician describing the patient's clinical condition and recommended "12/12 shift home care service" was reviewed. There is also a letter from the patient's treating neurologist also opining that the patient "needs home care supervision around the clock."  There are extensive treatment notes from the patient's providers.  In the most recent treatment not, the patient complained of fatigue and chronic back pain. The patient was described as "oriented x 3, normal mood and affect.  Ambulating with difficulty due to knee pain; balance disorder.  The patient is using a walker for ambulation."  The patient was seen by the nurse practitioner after a recent fall in the home was noted and "reports no injuries."  The patient "walks slowly with a rolling walker about 20-30 steps, unsteady gait, no new cardiac complaints since last visit."  The patient was also described as "Alert and oriented x 3."  A routine follow-up visit in 6 months was recommended.  

The reviewer would agree the patient may benefit from additional monitoring for safety; particularly due to their reported cognitive deficits, weakness and falls risk.  However, PCA hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance.  The approved (live-in) PCA is more appropriate and likely capable of consistently obtaining approximately 5 hours of uninterrupted sleep during the aide's 8-hours period of sleep.  

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 Home Care/Personal Care Level 2, Personal Care services, increase to 24 hours per day (split shift) is not substantiated.