Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure, Atrial Fibrillation

Treatment: Personal care assistance services (PAS) 12 hours per day, 7 days per week (Monday through Sunday), for a total of 84 hours per week

The insurer denied coverage for personal care assistance services (PAS) 12 hours per day, 7 days per week (Monday through Sunday), for a total of 84 hours per week

The denial is modified

This is a patient with chronic medical problems including heart failure, atrial fibrillation and asthma. The patient lives alone in a senior retirement facility.  The insurer approved personal care assistance (PCA) services 40 hours/week and the request is for 12 hours/day, 7 days/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 completing 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.  Extensive assistance is reportedly needed for dressing, locomotion, toilet transfer/use and ambulation.  The patient is independent for bed mobility and eating.  The patient reports being infrequently incontinent of bladder and bowel.  There have been no reported falls over the prior 90 days.  The patient's cognitive status and functional ability have modestly declined when compared to the previous UAS report (as a resident at a skilled nursing facility).  

The letter from the patient's treating physician describing the patient's clinical condition and need for "home attendant services 24 hours per day" was reviewed. The patient's provider also provides a treatment note.  The patient's provider does not document any specific physical findings or functional assessment to support his claim of the patient's reported functional incapacity.  There are no documented neuromuscular deficits.  The patient only has "trace leg edema."  Neurological examination is described as "Alert and oriented x 3, remainder grossly intact."  Also submitted for review is an Inpatient Discharge Summary, which does not provide any specific current clinical or functional ability information .  

The patient's medical condition and physical limitations are not at a level or unpredictable as to require PCA services 84 hours/week.  The patient may benefit from additional monitoring for safety; particularly due to the patient's reported limited mobility and falls risk.  However, PCA service hours are approved primarily to provide hands-on assistance for completion of IADL/Activities of Daily Living (ADL) tasks when no else is available to provide assistance; not primarily for safety monitoring.  Based on the records reviewed, the patient's functional impairments have modestly declined. The patient's  health and safety while in the home are more appropriately provided and maintained by increasing PCA services 8 hours/day, 7 days/week (56 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 assistance services 12 hours per day, 7 days per week (Monday through Sunday), for a total of 84 hours per week is not substantiated. However, PCA services 8 hours/day, 7 days/week are medically necessary.