Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, obesity, hypertension
Treatment: increase PCS (Personal Care Services) level 2; 63 hours/week
The insurer denied coverage for: increase PCS level 2; 63 hours/week
The denial is : Upheld
This is an adult with chronic medical problems including diabetes, obesity, hypertension and uses portable oxygen (O2). The patient lives with spouse (who receives mutual care) in a private residence. The insurer increased their Personal Care Services (PCS) level 2; from 20 to 28 hours/week. The patient requested an increase PCS level 2; 63 hours/week; leading to an external review. 
 
According to the Uniform Assessment System (UAS) report, the patients cognition is described as modified independent. The patient requires maximal assistance for completing much of their Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient requires limited assistance for bathing, personal hygiene, dressing, locomotion, toilet transfer/use, managing their portable oxygen equipment and ambulation. The patient is independent with bed mobility and eating. The patient is also fully continent of bladder and bowel. There has been no change in their ability to perform activity of daily living (ADL) tasks, self-sufficiency or reported falls over the prior 90 days. However, their functional ability has declined when compared to the UAS report.

The patient's  medical condition and physical limitations are not at a level or unpredictable as to require PCA services 63 hours/week. The patient was seen by nurse practitioner (NP) for pre-operative clearance prior to undergoing planned "local excision of right breast cancer recurrence." The patient was described as fully alert and oriented. There were no reported falls over the past year. This physician would agree, the patient may benefit from additional monitoring for safety; particularly due to their reported limited mobility and falls risk. However, personal care aide (PCA) service hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no else is available to provide assistance; not primarily for safety monitoring. Given their documented functional decline, increasing the PCA from 20 to 28 hours/week was clinically appropriate. Based on the records reviewed, the patient's health and safety while in the home are appropriately provided and maintained by the approved PCA 28 hours/week.

The healthcare plan acted with sound medical judgment and 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, an increase to 63 hours per week of personal care Level 2 services is not medically necessary.

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 to 63 hours per week of personal care Level 2 is not substantiated.