Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiomyopathy, Osteoarthritis

Treatment: Personal care services (PCS) 12 hours per day, 7 days a week totaling 84 hours

The insurer denied coverage for personal care services (PCS) 12 hours per day, 7 days a week totaling 84 hours

The denial is upheld 

This is patient with chronic medical problems including hypertension, cardiomyopathy and osteoarthritis. The patient lives alone in a private residence. The plan approved 7 hours/day, 5 days/week and 8 hours/day, 2 days/week, totaling 51 hours/week. The patient requested personal care services (PCS) 12 hours per day, 7 days a week totaling 84 hours, denied by the insurer, leading to an external review. 

The Uniform Assessment System (UAS) report is reviewed. The patient's cognitive skills are described as moderately impaired. The patient is reportedly total dependent to maximal assistance for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient also reportedly requires maximal assistance for bathing, lower body dressing and toilet use. The patient reportedly requires extensive assistance for personal hygiene, upper body dressing, eating, locomotion, toilet transfer and ambulation. Limited assistance is reportedly needed for bed mobility. The patient is reportedly frequently incontinent of bladder and continent of bowel. There have been no reported falls over the prior 90 days. 

The letter from the patient's treating physician describing the patient's clinical condition and need for additional personal care aide (PCA) services was reviewed. The patient's physician does not include associated treatment notes to support their assertion of the patient's reported functional incapacity. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested personal care services (PCS) 12 hours per day, 7 days a week totaling 84 hours. This physician would agree that the patient may benefit from monitoring for safety; particularly due to the patient's reported cognitive deficits, weakness and falls risk. PCA services for companion care or safety supervision (e.g., dementia, wandering, falls risk) without the direct provision of activities of daily living (ADL) task assistance is not a covered service. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved 7 hours/day, 5 days/week and 8 hours/day, 2 days/week, totaling 51 hours/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, the requested increase in personal care services (PCS) 12 hours per day, 7 days a week totaling 84 hours 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 services (PCS) 12 hours per day, 7 days a week totaling 84 hours is not substantiated.