Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Healing bilateral supracondylar distal femur fractures

Treatment: Live-in, 7 days/week of Personal Care Aide (PCA) services- Level 2

The insurer denied coverage for Live-in, 7 days/week of Personal Care Aide (PCA) services- Level 2. The denial upheld.

This patient is a female has been residing in a nursing home for over two years.  In recent months, the family decided to make arrangements to bring the patient home.  They requested 24 hour live-in PCA services.  The patient's husband lives at home and he plans to participate in the patient's care.  A Uniform Assessment System [UAS] was done. The insurer initially decided to approve PCA services 8 hours per day, 7 days per week.  Request for live-in was denied; appeal was requested.

The UAS from late-2019 indicates that the patient is dependent on assistance from caregivers for all daily activities (ADLs and IADLs).  The patient is non-ambulatory with lower extremity contractures.  She has substantial cognitive impairment (MMSE 12/30, poor decision making capacity, poor memory, not self-directing).  The initial decision to approve PCA 8 hours per day, 7 days per week does not appear to be supported by the UAS.  At the time the UAS was done, it was apparent that if the patient returned home, she would need 24 hour care.  The patient was dependent on caregivers for all bed mobility (which includes turning and repositioning on a regular basis during all hours the patient is in bed), and incontinence care (which can occur at any time and with varying frequency throughout the day and night).  The patient is at high risk for skin injury due to incontinence and immobility (e.g. dermatitis, pressure ulcers). In fact, the UAS indicated that the patient had a history of pressure ulcers that healed. 
In late-2019, the patient was diagnosed with bilateral femur fractures and was hospitalized.

The femur fractures required a new plan of care. With an acute fracture, it was necessary for all staff to be instructed on proper technique for moving the patient in bed, and transfer in and out of bed to ensure proper alignment of the fracture and prevent further damage.  ADL tasks must be done with caution to ensure that the patient's legs are moved safely during care.  The knee immobilizer needs to be removed at least twice per day for skin inspection (as per order). 

The patient was re-evaluated by PT and OT.  The reports indicated that the patient was dependent on caregiver assistance for all ADLs.  She was unable to sit up in a chair for more than 30 seconds. Additional instructions for proper care of the patient are necessary during this subacute post fracture period. The NH staff has been trained, and it their responsibility to perform all daily care for the patient based on the precautions required as a result of the patient's fractures.  It is not known whether this level of care is within the scope of practice for personal care aides. 

At this time, the available information for this review has not provided adequate confirmation that the care needs of the patient can be properly met at home by PCA services and the patient's husband or other informal caregiver. 

The request for 24 hour live-in, 7 days per week, personal care aide - level 2 services is denied. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. Based on the above, the medical necessity for the request for Live-in, 7 days/week of Personal Care Aide (PCA) services- Level 2 is not substantiated.  The insurer's denial is upheld.