Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Systemic Lupus Erythematous

Treatment: Personal care aide (PCA) services 84 hours/week, consumer direct, 1 client

The insurer denied coverage for personal care aide (PCA) services 84 hours/week, consumer direct, 1 client

The denial is modified

This case involves a patient who lives with a non-relative. The patient is diagnosed with anxiety, hypertension, hypothyroidism, mixed incontinence, rheumatoid arthritis, sarcoidosis, severe asthma, Sjogren syndrome, and systemic lupus erythematosus. The patient's medications include Acidophilus, Ambien, Bisacodyl, Cozaar, Gabapentin, Glucosamine, Ibuprofen, Levothyroxine, Percocet, Trelegy Ellipta, Tylenol, Duragesic patch.

The provider noted the patient requires split shift 24-hour care for when the patient returns home. The patient has a diagnosis of rheumatoid arthritis, systemic lupus erythematosus, abdominal aortic aneurysm repair, recurrent urinary tract infection (UTI), urinary retention, and thyroid disorder. The patient requires one person assist for sliding board transfers and set up for bed mobility. The patient is unable to ambulate and can self-propel in a wheelchair. The patient requires extensive assistance with dressing and needs the assistance of one person when using the toilet. 

According to the assessment, the patient is cognitively intact. The patient is totally dependent for housework and shopping. The patient requires maximal assistance with meal preparation. There is no history of wandering. The patient requires extensive assistance with dressing their lower body, bathing, toilet transfers, and toileting. The patient requires limited assistance with personal hygiene, bed mobility, and dressing their upper body. The assessment notes that the patient can transfer from the wheelchair to the toilet with a sliding board and one person assistance. The patient has urinary incontinence due to difficulty holding the urine and slow transitions. The patient cannot walk and utilizes a wheelchair which they can self-propel. 

The review found the patient is unable to transfer from their wheelchair with the transfer board without one person assist. The assessment did not allot any time for toilet transfers noting it wasn't observed. The doctor notes that the patient needs bed mobility set up. A split shift care would be appropriate for this patient; however, there is not a need for 24/7 care. Two 8-hour shifts would provide the care and assistance the patient needs to live in their home. The patient can work with the aide to determine what hours they want covered. Once they assist the patient to bed at night, there is not a need for assistance. Heavy duty diapers could be utilized so that the patient does not develop any urinary issues throughout the night. The decision is to award 16 hours per day 7 days per week for a total of 112 hours per week. The decision is partially overturned. 

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 personal care aide (PCA) services 84 hours/week, consumer direct, 1 client services is not substantiated. Rather, the decision is to award 16 hours per day 7 days per week for a total of 112 hours per week.