Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)

Treatment: PCA (Personal Care Aide) Level 2 services of 8 hours per day, 7 days per week for a total of 56 hours per week

The insurer denied coverage for PCA Level 2 services of 8 hours per day, 7 days per week for a total of 56 hours per week

The denial is overturned

The patient is a male with several chronic medical conditions associated with functional impairment resulting in the need for assistance with most daily activities. The Uniform Assessment System (UAS) the patient lives with his son. A community friend is serving as patient designee for the appeal process. The patient was receiving PCA services 31.5 hours per week; 4.5 hours per day, 7 days per week. The patient requested increase of PCA services to 56 hours per week; 8 hours per day, 7 days per week, which was denied. Internal appeal upheld denial of 56 hours per week, but increased PCA services to 45.5 hours per week; 6.5 hours per day, 7 days per week. The patient (via designee) requested an external appeal.

The patient has COPD. Based on the available records, it appears the patient's current pulmonary function is significantly diminished. The patient uses several medications for COPD including inhalation therapy with bronchodilators, and symbicort (combination steroid and long acting bronchodilator). He is oxygen dependent; using continuous oxygen 2 liters via concentrator at home. The UAS reports the patient has dyspnea with normal daily activities and needs frequent rest periods.  

It is also reported that the patient has frequent urinary incontinence. The UAS reports patient uses several pads per day; but the community friend who filed the appeal for the patient reported that the patient uses diapers, and he is unable to change diapers without assistance. The UAS nurse provided education to the patient regarding skin care and hygiene after each episode of incontinence; but this is not always possible when the patient is alone after episodes of incontinence. If the patient is unable to perform adequate self-care for incontinence, he may remain in a wet soiled diaper for an extended period of time, which increases the risk for incontinence associated skin damage, (e.g. dermatitis, fungal infection). 

The patient has substantial functional impairment and needs assistance for daily activities in his home from morning until he goes to bed at night. There are also concerns for the patient's health and safety during the night; e.g. toileting and incontinence care; fall risk if the patient attempts to get up from bed when alone; patient's ability to manage prn medications at night if he develops increased shortness of breath. It is not known how much, and what type of informal caregiver support the patient receives during non-PCA hours. The maximum amount of PCA hours that can be approved from this review is limited by the request for services as stated in the final adverse determination denial notice; in this case, PCA 56 hours per week. 

Personal Care Aide Level 2: 8 hours per day, 7 days per week; total of 56 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.                                                   

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 8 hours per day, 7 days per week for a total of 56 hours per week is reversed. Medical necessity is substantiated.