Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Chronic Kidney Disease

Treatment: Personal care aide (PCA) level 2: 10 hours per day - 7 days per week - for a total of 70 hours per week

The insurer denied coverage for personal care aide (PCA) level 2: 10 hours per day - 7 days per week - for a total of 70 hours per week

The denial is modified.

This is a patient with chronic medical problems including kidney disease, osteoarthritis and congestive heart failure. The patient lives in a 1 bedroom apartment and their daughter lives upstairs in a 2-story private residence. The insurer approved  Personal Care Aide (PCA) level 2: 38.5 hours/week . The patient requested PCA level 2: 10 hours/day, 7 days/week for a total of 70 hours/week, leading to an external review.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as modified independent. The patient reportedly requires maximal assistance for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing, locomotion, and ambulation. However, the patient is also able to ambulate with a walker. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility and toilet transfer/use. The patient is reportedly independent with eating. The patient is reportedly anuric (renal disease) and continent of bowel. There have been no reported falls over the prior 90 days. The patient's functional ability has declined compared to the previous UAS report.

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested Personal Care Aide (PCA) Level 2: 10 hours per day- 7 days per week- for a total of 70 hours per week. However, the clinical records document a functional decline that supports increasing PCA services. This physician would also agree that the patient may benefit from additional monitoring; particularly due to his reported cognitive decline and falls risk. However, safety monitoring under personal care services (PCS) does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided. Based on the documents reviewed, the patient's functional needs can be more appropriately provided and maintained by increasing PCA services 8 hours/day, 7 days/week, total 56 hours/week. The patient also has the option of restructuring and flexibly using the 56 PCA hours weekly to better maintain and meet their functional needs. 

The healthcare plan did not act reasonably, with sound medical judgment or 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, Personal Care Aide (PCA) Level 2: 10 hours per day- 7 days per week- for a total of 70 hours per week is not medically necessary. However, Personal Care Aide (PCA) Level 2: 8 hours per day- 7 days per week- for a total of 56 hours per week is medically necessary.

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: 10 hours per day - 7 days per week - for a total of 70 hours per week is not substantiated. However, Personal Care Aide (PCA) Level 2: 8 hours per day- 7 days per week- for a total of 56 hours per week is medically necessary.