Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, Osteoarthritis.

Treatment: Personal Care Aide (PCA) 12 hours per day, 7 days per week.

The insurer denied coverage for Personal Care Aide (PCA) 12 hours per day, 7 days per week.

The denial is upheld.

This is a patient with multiple medical problems including dementia, atrial fibrillation, and osteoarthritis. The patient lives with their daughter (who assists with their care) and the daughter's family in a private residence. The insurer approved Personal Care Aide (PCA) services 10 hours/day, 7 days/week and the request is for PCA services 12 hours/day, 7 days/week, which to an external review. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as moderately impaired. The patient reportedly, "is unable to make needs known, cannot self-direct, and is unable to make any decisions." The patient is reportedly totally dependent on completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient is reportedly totally dependent on bathing, locomotion, toilet transfer/use, and ambulation. Maximal assistance is reportedly required for dressing and extensive assistance for personal hygiene. The patient reportedly requires limited assistance for bed mobility and eating. The patient is reportedly frequently incontinent of the bladder and occasionally incontinent of the bowel. The patient's activities of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. The patient's functional ability has also modestly declined when compared to the UAS report.

The patient's medical condition and physical limitations are not at the level or unpredictable as to require the requested PCA services 84 hours/week. This physician would agree the patient may benefit from monitoring for safety, particularly due to his reported weakness and cognitive deficits. However, PCA service hours are approved primarily to provide hands-on assistance for the completion of IADL/ADL tasks when no one else is available to provide assistance; not primarily for safety monitoring (e.g., dementia). Based on the records reviewed, the patient's health and safety are appropriately provided and maintained by shared household responsibilities of the other adults living in the home and the approved PCA services 10 hours/day, 7 days/week. Splitting the daily 10-hour shift to perhaps (2) five-hour shifts may also be a PCA service option. 

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, the 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, PCA services 12 hours/day, 7 days/week are not medically necessary for this patient. 

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 Personal Care Aide (PCA) 12 hours per day, 7 days per week is not substantiated.