Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic brain injury.

Treatment: Personal care assistance (PCA) 30 hours per week.

The insurer denied coverage for personal care assistance (PCA) 30 hours per week.

The denial is upheld.
 

The patient is having the diagnoses of diabetic ketoacidosis (DKA) and traumatic brain injury (TBI) with a history of autism spectrum disorder. The patient does not have any motor or functional impairment. He does have decreased strength. The patient has not been cooperative with psychological testing and has had emotional and behavioral issues. His parents would like him to get a job, but he has no work history prior to his TBI. The request is for personal care assistance (PCA) 30 hours per week.

The patient has functional motor and sensory function. He does not have any evidence of worsening function since TBI.      

The patient is a Type I diabetic who slipped into a coma which lasted 10 weeks and resulted in traumatic brain injury (TBI).  The effect of his TBI is short term memory loss, loss of executive skills, and a seizure disorder.  He experiences significant cognitive impairment.  In order to sufficiently care for his Type 1 diabetes he needs help with taking medications, eating properly and taking the correct amount of short and long acting insulin.  He has a Dexcom sensor and transmitter. These medical tasks require a non-impaired brain without loss of short term memory and executive skills.  His "memory issues" have resulted in numerous emergency room (ER) visits and hospitalizations in the past year for hypoglycemia and ketoacidosis.  In addition, emotional issues, particularly anger have caused him to be a danger to himself.

According to the Uniform Assessment System (UAS) he was reported to be short of breath and verbally abusive.  He is trying to establish himself in his own apartment so that he may live alone. The UAS notes he requires assistance with instrumental activities of daily living (IADLs) such as managing medications and insulin on a frequent basis, shopping and housekeeping.  Decision making is consistently poor or unsafe.  Currently his Mother was providing cues and reminders to take medications.  The patient is unable to verbalize how to call 911 in an emergency.

Specifically, the patient needs maximal assistance with shopping,  meal preparation and ordinary housework.  He is totally dependent for managing finances and requires extensive assistance for managing frequent medications. He is independent in activities of daily living (ADLs). It should also be noted that increased PCA service cannot help in management of his diabetes. 

The patient is currently receiving 13 hours per week. There is no need for additional hours. Therefore, the Personal care assistance (PCA) 30 hours per week is not medically necessary for this patient.

"ADL is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Measurement of an individual's ADL is important as these are predictors of admission to nursing homes, need for alternative living arrangements, hospitalization, and use of paid home care. The outcome of a treatment program can also be assessed by reviewing a patient's ADLs." (Edemekong, P. F., et al. 2022).

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 assistance (PCA) 30 hours per week is not substantiated.