Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis, coronary artery disease and dementia.
Treatment:  Personal Care Aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift), for a total of 168 hours per week

The insurer denied coverage for Personal Care Aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift), for a total of 168 hours per week.  The denial is modified.

This is an elderly patient with chronic medical problems including osteoarthritis, coronary artery disease and dementia. She lives with her spouse in a 1 bedroom apartment. The patient usually attends social day care services 2 times/week and is authorized by the insurer for a PCA 4 hours/day, 5 days/week for a total of 20 hours/week. Under review are the requested increase in PCA services: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split-shift), for a total of 168 hours/week.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as "moderately impaired" and reportedly has declined over the prior 90 days. For comparison, the previous UAS report described her cognition as "minimally impaired." The patient currently "is not self-directing, not able to verbalize the emergency plan, and supervision required at all times." The patient has been found wandering 3-4 times in last 3 months and the ability to perform activities of daily living has also declined compared to the previous UAS report. The patient now requires extensive assistance for bathing, personal hygiene, dressing and toilet transfers/use, and is frequently incontinent of bladder and continent of bowel. Limited assistance is needed for bed mobility and locomotion. A cane is used for ambulation.  

The patient's cognitive and functional decline supports the medical necessity of increasing PCA services. The described condition and functional needs are not at a level or unpredictable as to require the requested PCA services: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split-shift), for a total of 168 hours/week.  The patient may require 24-hour monitoring. Safety monitoring under personal care services does not include monitoring an individual (e.g., dementia) 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 by supportive family, and increasing PCA services to 8 hours/day, 7 days/week for a total of 56 hours. 

From a physical medicine and rehabilitation perspective, the requested Personal Care Aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift), for a total of 168 hours per week is not medically necessary.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. 

The insurer's denial of coverage for the increase in Personal Care Aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift), for a total of 168 hours per week is modified. 

Medical Necessity is substantiated for Personal Care Aide (PCA) services to 8 hours/day, 7 days/week for a total of 56 hours.