Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple myeloma, diabetes and lumbar radiculopathy

Treatment: Increase in Personal Aide Services (PCA), 12 hours per day, 7 days per week, for a total of 84 hours per week

The insurer denied coverage for increase in Personal Aide Services (PCA), 12 hours per day, 7 days per week, for a total of 84 hours per week

The denial is upheld
 

This is an adult female with chronic medical problems including multiple myeloma, diabetes and lumbar radiculopathy.  She lives alone in a 1-bedroom apartment.   The insurer approved Personal Aide Services, 10hours per day, 7 days per week, for a total of 70 hours per week.  The insurer denied the request for an increase in Personal Aide Services, to 12 hours per day, 7 days per week, for a total of 84 hours per week; leading to an external review.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as modified independent.  She is able to call 911 in an emergency.  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 toilet use and ambulation.  Extensive assistance is reportedly needed for bathing, personal hygiene, dressing, locomotion and toilet transfer.  Limited assistance is reportedly needed for bed mobility and independent for eating.  The patient is reportedly frequently incontinent of bladder and occasionally incontinent 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 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 increase in Personal Aide Services, 12 hours per day, 7 days per week, for a total of 84 hours per week.  The letters from the patient's treating providers respectively; discussing her underlying medical condition and recommending additional  Personal Aide Services were also reviewed.   However, they did not include the associated treatment notes to support their claim of the patient's reported functional incapacity.  

The patient may benefit from additional monitoring for safety; particularly due to her reported fatigue, weakness and falls risk.  However, PAS hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no else is available to provide assistance.   Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the approved Personal Aide Services, 10 hours per day, 7 days per week, for a total of 70 hours per week.  The patient also continues to have the option of restructuring and flexibly using the 70 Personal Aide Service hours weekly to better maintain and meet her functional needs.

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 Aide Services, 12 hours per day, 7 days per week, for a total of 84 hours per week is not substantiated.