Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Diabetes, Chronic Back Pain

Treatment: Increase in personal care aide hours from 7 days a week 5 hours a day to 7 days a week 24 hours a day (Live-In)

The insurer denied coverage for increase in personal care aide hours from 7 days a week 5 hours a day to 7 days a week 24 hours a day (Live-In)

The denial is modified

This is a patient with diagnoses that include diabetes, hypertension and chronic back pain.  The patient lives alone in a multi-level private residence.  The patient's daughter assists with their medications and acts as a back-up caregiver.  The insurer approved personal care aide (PCA) services 5 hours/day, 7 days/week.  The insurer denied the patient's request for  PCA services 7 days a week, 24 hours a day (live-in), leading to an external review.

The Uniform Assessment System (UAS) report notes the patient's cognition is described as "moderately impaired."  However, the patient "can call 911 in an emergency."  The patient is reportedly total dependent for performing much of their Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping.  The patient reportedly requires maximal assistance for bathing, lower body dressing and toilet use.  Extensive assistance is reportedly required for personal hygiene and upper body dressing.  Limited assistance is reportedly needed for eating, bed mobility, locomotion, toilet transfer and ambulation. There has been 1 reported fall over the prior 30 days.  

The patient is reportedly frequently incontinent of bladder and continent of bowel.  The patient's activities of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.  The patient's functional ability has also declined when compared to the previous UAS report; particularly for bathing, personal hygiene, dressing and toilet use.  

The patient's condition and functional deficits are not at a level or unpredictable as to require a live-in PCA.  However, the patient's functional ability has declined and supports increasing PCA 10 hours/day, 7 days/week for a total of 70 hours/day.  The reviewer would agree the patient may benefit from additional monitoring for safety.  However, safety monitoring under PCA does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained with increasing PCA services to 70 hours/week.   

The healthcare plan did not act reasonably, with sound medical judgment or 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, boards and associations.  All decisions are evidence-based).   

From a physical medicine and rehabilitation perspective, the requested increase in Personal care Aide (PCA) services to live-in is not medically necessary.  However, increasing PCA services to 10 hours/day, 7 days/week (70 hours/week) is medically necessary.

Based on the above, the insurer's denial must be modified. 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 increase in personal care aide hours from 7 days a week 5 hours a day to 7 days a week 24 hours a day (Live-In) services is not substantiated.  However, an increase in personal care services to 10 hours per day for 7 days/week for a total of 70 hours is justified.  Therefore, the insurer's decision is modified.