Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Memory Problems, Cerebrovascular Accident, Peripheral Artery Disease 

Treatment: Increase in Personal Care Aide (PCA) services, Level 2: 8 hours per day, 7 days per week - for a total of 56 hours per week

The insurer denied coverage for increase in Personal Care Aide (PCA) services, Level 2: 8 hours per day, 7 days per week - for a total of 56 hours per week

The denial is modified

This is a patient with diagnoses that include stroke, dementia and osteoarthritis. The patient lives with their adult granddaughter.  The patient's daughter is the paid caregiver.  The insurer approved increasing Personal Care Aide (PCA) services from 3 hours/day, 7 days/week to 4 hours/day, 7 days/week and the request is for PCA level 2: 8 hours/day, 7 days/week - for a total of 56 hours/week; leading to an external review.

The Uniform Assessment System (UAS) report states the patient's cognition is described as "minimally impaired."  The patient reportedly requires extensive assistance to total dependence for performing much of their Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping.  The patient reportedly requires maximal assistance for bathing and lower body dressing.  Extensive assistance is reportedly needed for upper body dressing and toilet transfer/use.  Limited assistance is reportedly needed for personal hygiene, bed mobility, locomotion and ambulation.  The patient is independent with eating.  The patient reports being occasionally incontinent of bladder and continent of 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 condition and functional deficits are not at a level or unpredictable as to require an increase PCA 56 hours/week.  However, the patient's cognitive and functional declined support increasing PCA level 2: 6 hours/day, 7 days/week- for a total of 42 hours/week.  This physician would agree the patient may benefit from additional monitoring for safety.  However, safety monitoring under PCA does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained with increasing PCA services 42 hours/week and share household responsibilities of the other adult living in the home.   

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, the requested increase in Personal care Aide (PCA) services, Level 2: 8 hours per day, 7 days per week - for a total of 56 hours per week is not medically necessary; however, PCA services Level 2: 6 hours per day, 7 days per week - for a total of 42 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 increase in Personal Care Aide (PCA) services, Level 2: 8 hours per day, 7 days per week - for a total of 56 hours per week is not substantiated. However, PCA services Level 2: 6 hours per day, 7 days per week - for a total of 42 hours per week is medically necessary.