Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes

Treatment: Increase in Personal Care Aide (PCA) services for a total amount of 56 hours per week (8 hours per day - 7 day(s) per week)

The insurer denied coverage for increase in Personal Care Aide (PCA) services for a total amount of 56 hours per week (8 hours per day - 7 day(s) per week).

The denial is upheld.

This is a patient with chronic medical problems including hypertension, diabetes and back pain.  The patient currently lives alone after their spouse recently passed away.  The insurer approved personal care aide (PCA) services level 2: 3 hours/day, 5 days/week and 4 hours/day 1 day/week (total 19 hours/week).  The request is for PCA services, 8 hours per day - 7 days per week (56 hours/week), which was denied by the insurer, leading to an external review.

The Uniform Assessment System (UAS) report was reviewed.  The patient indicated "I need help for cooking, shopping and housework."  The patient's cognition was described as modified independent.  The patient reportedly requires maximal assistance to total dependence for completing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing and lower body dressing.  Limited assistance is reportedly needed for toilet transfer, locomotion and ambulation.  The patient is otherwise independent for bed mobility, eating and toilet use.  There has been no change in the patient's ability to perform activities of daily living (ADLs), self-sufficiency or reported falls over the prior 90 days.  The patient's cognitive and functional ability are also much the same when compared to the previous UAS report. 

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested PCA services; 8 hours per day - 7 days per week (56 hours/week).  The letter from the patient's treating physician describing the patient's clinical condition and functional ability was reviewed.   The patient reportedly "could get lost easily and walks alone on the street.  The patient needs supervision."  The physician also notes the patient "is able to perform ADL such as bathing himself, ambulating with a walker and eating."  The physician also notes "it became apparent to me that 3 hours/day of health aide (HA) services are adequate for the patient."  The physician concludes the patient "requires assistance with monitoring and oversight for IADLs to remain safe in the community and avoid adverse outcomes."  The physician's treatment notes were also reviewed.  There is no documented specific functional assessment; however, the latter note indicates the patient "ambulates independently."   

The reviewer would agree the patient may benefit from additional monitoring for safety; particularly due to the patient's reported progressive cognitive decline, weakness and falls risk.  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 submitted clinical records, the patient's health and safety are appropriately provided and maintained at home by the approved PCA services 19 hours/week.  

From a physical medicine and rehabilitation perspective, PCA services for a total amount of 56 hours per week (8 hours per day- 7 days per week) is not medically necessary.  

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 an increase in Personal Care Aide (PCA) services for a total amount of 56 hours per week (8 hours per day - 7-day(s) per week) is not substantiated.