Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, pancreatic cancer and depression. 
Treatment: Personal Care Aide (PCA) Level 2: 24 hours per day - Live-in per diem - 7 days a week. 

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 24 hours per day - Live-in per diem - 7 days a week. 

The denial is modified. 

This is an adult female with medical problems including diabetes, pancreatic cancer and depression.  She is currently residing in a skilled nursing facility (SNF). The plan is for her to return home to her private residence where she lives alone.  The insurer approved Personal Care Aide (PCA) services 7 hours per/day, 7 days/week and the request is for Personal Care Aide (PCA) services 7 days/week, 24 hours/day, live in. 

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as minimally impaired.  She is reportedly totally dependent for much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She is also reportedly totally dependent for locomotion.  Maximal assistance is reportedly required for bathing, bed mobility and toilet use.  Extensive assistance is reportedly needed for personal hygiene, dressing, eating, toilet transfer and ambulation. The patient is reportedly frequently incontinent of urine and continent of bowel. 

The patient's Activities of Daily Living (ADL) status and self-sufficiency have reportedly declined, and she has fallen over the prior 90 days.   The patient's cognitive status and functional ability have also significantly declined when compared to the Uniform Assessment System (UAS).  However, the therapy notes from the Skilled Nursing Facility document the patient as having a higher level of function than described in the Uniform Assessment System (UAS) report.   According to the physical therapy notes, the patient is independent for bed mobility and at the supervision level for locomotion.  

The patient's medical condition, physical limitations and functional ability are not at the level or unpredictable as to require the requested Personal Care Aide (PCA) services 24 hours/day live-in.   

This physician would agree the patient may benefit from additional monitoring; particularly due to her reported weakness and falls risk.  Safety monitoring under Personal care Services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.  However, upon her eventual return home, the patient's functional ability is unlikely to be at the level documented by the treating therapists at the Skilled Nursing Facility; but also, not likely as described in the Uniform Assessment System (UAS) reports.  Based on the records reviewed and discussed above, attention to the patient's functional needs is appropriately provided and maintained by increasing Personal Care Aide (PCA) services to 10 hours/day, 7 days/week totaling 70 hours/week. 

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) Level 2: 24 hours per day - Live-in per diem - 7 days a week services is not substantiated. However, PCA level 2: 10 hours per day- live-in per diem- 7 days a week (total 70 hours) is medically necessary.