Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: chronic obstructive pulmonary disease (COPD), hypertension and osteoarthritis

Treatment: increase in personal care aide service hours to 7 days per week, 24 hours per day, split shift

The insurer denied coverage for increase in personal care aide service hours to 7 days per week, 24 hours per day, split shift

The denial is modified.


This is an elderly female with chronic medical problems including chronic obstructive pulmonary disease (COPD), hypertension and osteoarthritis.  She is currently a resident in a skilled nursing facility with the goal to return to her private residence.  The insurer approved personal care aide (PCA) services 12 hours/day- 7 days/week- for a total of 84 hours/week.  The insurer denied the request for an increase in personal care aide (PCA) service hours to 7 days per week, 24 hours per day, split shift. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as moderately impaired.  She is reportedly totally dependent for performing much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient is also reportedly totally dependent for bathing, lower body dressing and toilet transfer/use.  She is frequently incontinent of bladder and occasionally incontinent of bowel.  Extensive assistance is reportedly required for personal hygiene, upper body dressing and bed mobility.  She requires a Hoyer lift for transfers and is non-ambulatory.  She is pushed in a manual wheelchair for mobility.  Limited assistance is reportedly needed for eating.  The patient's ability to perform activities of daily living and self-sufficiency have reportedly declined and deteriorated, respectively, over the prior 90 days.  She has fallen on at least 2 occasions over the prior 90 days.  The patient's cognitive and functional ability have also declined when compared to the previous Uniform Assessment System (UAS) report.

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require persona; care aide (PCA) services 7 days per week, 24 hours per day (split shift).  However, the patient's cognitive and functional deficits are substantial; the approved personal care aide (PCA) services 84 hours/week are inadequate as she attempts to transition from the nursing facility to home.  Based on the clinical records, a live-in personal care aide (PCA) is more appropriate and likely capable of consistently obtaining approximately 5 hours of uninterrupted sleep during the aide's 8-hours period of sleep.  Attention to the patient's functional needs are more appropriately provided and maintained via personal care aide (PCA) services 7 days/week, 24 hours/day (live-in).  

From a physical medicine and rehabilitation perspective, an increase in personal care aide service hours to 7 days per week, 24 hours per day, split shift is not medically necessary.  However, personal care aide (PCA) services 7 days/week, 24 hours/day (live-in) are 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 an increase in personal care aide (PCA) hours to 7 days per week, 24 hours per day, split shift services is not substantiated. However, personal care aide (PCA) services 7 days/week, 24 hours/day (live-in) are medically necessary.