Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes, and depression. 
Treatment: Personal care assistance (PCA) services 119 hours per week. 
The insurer denied coverage for personal care assistance (PCA) services 119 hours per week. 
The denial is modified. 

This is an elderly female with chronic medical problems including hypertension, diabetes, and depression. She lives with her daughter who reportedly has "a cognitive impairment."  The insurer approved 33 personal care assistance (PCA) service hours per week. The patient requested an increase to 119 PCA service hours per week, denied by the insurer which led to an external review. 

According to the Uniform Assessment System (UAS) report the patient's cognition is described as modified independent. She is "self-directing, able to make decisions, and can be left alone." The patient's ability to perform much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping; varies from extensive assistance to total dependence. The patient is also reportedly totally dependent on locomotion, toilet use, and ambulation (reportedly "wheelchair bound"). The patient "transfers from wheelchair to her bed using a walker, she can stand for a few minutes (1-2)." Maximal assistance is reportedly required for bathing and lower body dressing. Extensive assistance is reportedly needed for personal hygiene and upper body dressing. She is independent in eating. The patient is reportedly frequently incontinent of bladder and bowel. The patient's activities of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. There have been no reported falls over the prior 90 days. 

A letter from the patient's treating physician describing her clinical condition and reporting the need for additional PCA services was reviewed. This doctor does not include his associated treatment notes to support his claim of the patient' reported functional incapacity. He also notes the patient lives with her adult daughter who reportedly is "disabled, has been disabled for a long time, and is unable to provide personal care for her mother." 

The patient's ADL status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. Her physical impairments are substantial. However, the patient's functional needs are not at a level or unpredictable as to require the requested PCA service hours of 119 hours per week. Based on the submitted clinical records, the patient's health and safety are appropriately provided and maintained at home by increasing PCA services to 10 hours/day, 7 days/week: totaling 70 hours/week. The patient may also have the option of restructuring and flexibly using the 70 PCA Service hours weekly (perhaps 2 shifts) to better maintain and meet her functional needs. 

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 assistance (PCA) services 119 hours per week services is not substantiated. Increasing PCA services to 70 hours/week is medically necessary.