Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Heart Disease, Dysphagia, Bladder Cancer

Treatment: Personal care assistance services 24 hour live in, 7 days per week

The insurer denied coverage for personal care assistance services 24 hour live in, 7 days per week

The denial is modified

This is a patient with medical problems including heart disease, dysphagia and bladder cancer. The patient lives alone in a private residence. The patient's niece is the paid caregiver. The patient was receiving personal care assistance (PCA) services 36 hours/week (6 days/week) and requested 24 hour live in PCA services 7 days a week. The insurer increased PCA services to 49 hours/week, leading to external review for the requested PCA services (live-in) 7 days a week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired. The patient is able to use their Personal Emergency Response System (PERS) if needed. According to their niece, the patient wanders overnight through the apartment building. The family has installed cameras in the apartment for monitoring. The patient reportedly requires maximal to extensive assistance for much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires extensive assistance for bathing and toilet transfer. Limited assistance is reportedly needed for personal hygiene, dressing, locomotion and ambulation. The patient is independent with bed mobility and eating. The patient is reportedly frequently incontinent of urine and continent of bowel. The patient's activities of daily living (ADL)  status and self-sufficiency have reportedly not changed and there have been no reported falls over the prior 90 days. 

The patient's medical condition, physical limitations and functional ability are not at the level or unpredictable as to require live-in PCA services. The letter from the patient's treating physician, describing the patient's clinical condition and reported need for "7 days 24 hours of care" was reviewed. However, the patient's provider does not provide associated treatment notes to support the assertion of the patient's functional incapacity. 

It is agreed that the patient may benefit from additional monitoring; particularly due to their reported weakness and wandering during the evenings. However, safety monitoring under PCS does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided. Based on the records reviewed and discussed above, attention to the patient's health and safety can be appropriately provided and maintained by modestly increasing PCA to 10 hours/day (perhaps 2 separate shifts), 7 days/week totaling 70 hours/week.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based. 

From a physical medicine and rehabilitation perspective, personal care assistance (PCA) services 24 hour live in 7 days a week is not medically necessary. However, increasing PCA services to 10 hours/day, 7 days/week is medically necessary.

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 assistance services 24 hour live in, 7 days per week is not substantiated. However, increasing PCA services to 10 hours/day, 7 days/week is medically necessary.