Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: hypertension, spinal stenosis and radiculopathy

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

The insurer denied coverage for Personal Care Aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day-7 days per week- for a total of 168 hours per week (split-shift)

The denial is modified

 
This is an elderly female with chronic medical problems including hypertension, spinal stenosis and radiculopathy. She lives alone in a private residence. Her husband recently died and had reportedly assisted her when the personal care aide (PCA) was not present. Her son, who also provided assistance, no longer lives in the area. The patient's daughters remain involved in her care. The insurer approved PCA 6.5 hours/day- 7 days/week- for a total of 45.5 hours/week. The insurer denied the request for PCA Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - for a total of 168 hours per week (split-shift); leading to an external review. 

According to the Uniform Assessment System (UAS) report the patient's cognition is described as modified independent. She reportedly requires maximal assistance to total dependence for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing, toilet transfer, locomotion and ambulation. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility and toilet use. She is independent for eating. The patient is reportedly frequently incontinent of bladder and continent of bowel. There has been no reported change regarding her activities of daily living (ADL) status, self-sufficiency or reported falls over the prior 90 days. The patient's cognitive and functional ability are much the same when compared to the prior Uniform Assessment System (UAS) report.

Based on the submitted documents reviewed, the patient does not have functional needs at a level or unpredictable as to require the requested PCA Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - for a total of 168 hours per week (split-shift). The letter from the patient's treating physician, discussing her underlying medical condition and recommending "24-hour care" was also reviewed. The doctor does not include the associated treatment notes to support his claim of the patient's reported functional incapacity. 

This physician would agree the patient may benefit from additional monitoring for safety; particularly due to her reported weakness and falls risk. However, PCA hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no else is available to provide assistance. This physician would also agree the patient's functional deficits are substantial and she no longer has much of the informal care that was previously provided by family. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by increasing PCA to 12 hours/day, 7 days/week; totaling 84 hours/week. The patient also has the option of restructuring and flexibly using the 84 PCA hours weekly to better maintain and meet her functional needs.

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 Personal Care Aide level 2: 12 hours per day- 7 days per week; 12 hours per day-7 days per week- for a total of 168 hours per week (split-shift) services is not substantiated. However, increasing PCA to 12 hours/day, 7 days/week; totaling 84 hours/week is medically necessary.