Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, Ulcerative Colitis, Dementia

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - for a total of 168 hours per week (split-shift)

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - for a total of 168 hours per week (split-shift)

The denial is overturned

The patient has chronic medical problems, including hypertension, ulcerative colitis, and dementia.  The patient lives alone in a 2-bedroom apartment.  The patient reportedly had a friend come to stay with them.  However, this is no longer feasible given the friend's own personal health conditions.  The insurer approved patient care aide (PCA) 16 hours/day - 2 days/week; 12 hours/day - 5 days/week and 12 hours/day - 5 days/week - for a total of 152 hours/week.  The insurer denied the request for PCA level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - for a total of 168 hours per week (split-shift), leading to an external review.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as severely impaired.  The patient "doesn't recognized caregivers and doesn't (know) where the patient is."  The patient is reportedly totally 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, personal hygiene, dressing, eating, bed mobility, locomotion, toilet transfer and ambulation.  The patient is totally dependent for toilet use as well as being incontinent of bladder and bowel.     

The patient's functional ability and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.  However, the patient's cognitive and functional ability are much the same when compared to the previous UAS report.  The patient's clinical condition and functional deficits are at a level and unpredictable as to require PCA services 7 days per week, 24 hours per day (split shift).  The patient is currently receiving PCA split-shift 5 days/week and 16 hours/day, 2 days/week.  The remaining 16 hours/week had been informally "covered" by a family friend, who is no longer available.  Filling the care void by extending PCA for the additional 16 hours/week for resultant PCA services 7 days per week, 24 hours per day (split-shift) is clinically appropriate and medically necessary.  Based on the clinical records, a live-in PCA is also unlikely capable of consistently obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift.  The letter from the patient's treating physician discussing the patient's underlying medical condition and need for PCA "24 hours a day, 7 days a week" was also reviewed.  

The reviewer would agree with the patient's treating physician that attention to the patient's functional needs are more appropriately provided and maintained by the PCA 7 days per week, 2-12-hour shifts (split-shift).

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 (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - for a total of 168 hours per week (split-shift) is substantiated.