Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, hypothyroidism, osteoarthritis, and sciatica

Treatment: Personal care aide (PCA) level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week

The insurer denied coverage for PCA level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week.

The denial is overturned.


This elderly patient has physical and cognitive impairment associated with various medical conditions and needs assistance with all daily activities. The patient lives with her daughter. The patient receives personal care aide (PCA) services 56 hours/week to assist with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The daughter provides informal help during the evening and night (PCA is present 8 hours/day during daytime hours; daughter is at work). The daughter reported that prior to PCA services, she paid for a private aide to help her mother during the hours the daughter was not available. The daughter indicated that she is unable to continue providing care for her mother on a regular basis during evening and night hours due to her work schedule and her need to sleep at night. She is unable to continue private pay aide services. The daughter (as patient designee) requested increase of PCA services to 24 hours/day, split shift, which was denied. 

The most recent Uniform Assessment System (UAS) provided was reviewed. The functional status report for IADLs indicated patient is totally dependent for meal preparation, ordinary housework, managing finances and medications, shopping; she needs maximal assistance for stairs, phone use, transportation. For ADLs, she is totally dependent for toilet use, eating; she needs maximal assistance for bathing, personal hygiene, dressing upper/lower body; extensive assistance for walking, locomotion transfer toilet; limited assistance for bed mobility.

The UAS indicates patient has moderate difficulty with vision; as per daughter, patient is unable to see with her left eye. She also has moderate difficulty hearing. She has hearing aids but refuses to use them. 

The patient has poor mobility. She has pain, weakness, impaired balance, unsteady gait that limits her ability to transfer and walk and increases her risk for falls. She needs an assistive device (cane or walker) and caregiver assistance for transfers and walking. The daughter reported the patient has poor safety awareness. When a caregiver is not present, the patient tries to get up unassisted and does not remember to use the assistive device, which has resulted in falls. At night, the daughter uses a motion sensor for the patient, which alerts the daughter when the patient is trying to get up from bed. Even with the motion sensor, the patient may get up from bed and fall before the caregiver wakes up and reaches the patient. The need for a caregiver in this situation is not for safety supervision, it is for ADL assistance for mobility (transfer and walking), which the patient cannot perform safely alone. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for PCA level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week services is substantiated.