Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)

Treatment: Personal Care Aide (PCA) level 2 services of 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The insurer denied coverage for PCA level 2 services of 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The denial is overturned

This male with diagnoses: severe COPD on 5 Liter oxygen, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), depression, spinal stenosis, back pain, arthritis, bursitis, pre-diabetes. The patient was hospitalized with 2019 Novel Coronovirus (COVID-19) infection and since then his condition is worse. Prior to hospitalization the patient had trouble walking due to arthritis, and could not walk a few steps without shortness of breath. He is now wheelchair bound and has difficulty getting in and out of bed. He wakes up several times at night. His incontinence is worse (urine and stool). He needs several nebulizer treatments during the night and cannot administer treatment independently. He has progressive memory loss. He needs assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). It is imperative for the patient to have 24 hour care.

The patient has severe functional impairment associated with various medical conditions.  He needs assistance from caregivers for all daily activities.  He receives personal care aide (PCA) services 9.5 hours per day, 66.5 hours per week.  The records provided by the insurer include Clinical Review Checklist indicating the patient lives with his wife; she receives live-in services, 13 hours x 7 days per week.  It is not clear whether this is a mutual case.  The patient was hospitalized due to COPD, acute respiratory failure and COVID-19 infection.  The patient (via designee) requested PCA services 24 hours split shift, which was denied.  External appeal was requested.

The patient has several chronic medical conditions that are probable causes of his progressive functional impairment.  The recent hospitalization most likely contributed to further physical and cognitive decline.

The patient has chronic obstructive pulmonary disease.  Full history of his respiratory disease is not available; but based on recent information his current pulmonary function appears severely impaired.  He has dyspnea with normal activity; low endurance, poor activity tolerance. The Uniform Assessment System (UAS) indicates he needs maximal assistance for walking, and it appears his mobility is mostly in a wheelchair, propelled by caregivers.  He uses oxygen continuously, 5 Liter nasal cannula.  Medications include albuterol/ipratropium via nebulizer, incruse ellipta, tiotropium inhaler, albuterol inhaler, Advair diskus. 

The patient has multiple sources of chronic pain.  The records indicate he has osteoarthritis and rheumatoid arthritis; specific joints are not noted.  The UAS indicates patient has lower back pain and spinal stenosis.  There is reference to prior surgery for spinal stenosis but no details are available.  The UAS reports hand pain (possibly due to arthritis) which can affect routine daily tasks requiring manual dexterity.  The patient has rotator cuff tear (noted as bilateral in UAS) which is reported as a cause of substantial functional impairment due to decreased range of motion of shoulders; requiring caregiver assistance for multiple ADLs including bathing, personal hygiene, upper body dressing, toilet use. 

Considering the severity of the patient's pulmonary disease, his physical limitations for self-help, and his cognitive limitations (impaired memory and judgment) it is in the patient's best interest to have a caregiver present who can provide assistance to help improve compliance with treatment, relieve discomfort (e.g. repositioning) and provide the patient with some reassurance. 

Based on the information provided for review, it is apparent that the patient is at high risk for adverse health and safety events, including: respiratory distress; falls and injury; skin damage due to inadequate incontinence care and/or inadequate pressure relief.  

The patient needs assistance for all daily activities; including those that occur at unscheduled times during the day and night. It does not appear his care needs can be adequately met within the service hours provided by a live-in aide (13 hours per day).  Therefore, PCA continuous services (split shift) are indicated.

Personal Care Aide Level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is reversed. Medical necessity is substantiated.