Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular disease, Osteoarthritis, Cancer, Diabetes

Treatment: Personal care assistance services (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week

The insurer denied coverage for personal care assistance services (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week.

The denial is modified.

This is a patient with chronic medical problems including diabetes, heart failure, stroke and atrial fibrillation.  The patient lives alone in a 1-bedroom apartment.  The insurer approved personal care assistance services (PCA) services level 2: 7 hours/day, 7 days/week for a total 49 hours/week and the request is for PCA services level 2: 7 days per week, 24 hours per day (split shift), for a total of 168 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as minimally impaired.  The patient is self-directing, able to call 911 in an emergency and utilize a Personal Emergency Response System (PERS) if needed.  The patient reportedly requires maximal assistance to total dependence for performing much of their Instrument Activities of Daily Living (IADLs) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires maximal assistance for bathing, dressing, bed mobility, toilet transfer/use and ambulation.  Extensive assistance is reportedly needed for personal hygiene.  Limited assistance is reportedly needed for eating.  The patient is reportedly frequently incontinent of bladder and continent of bowel.  The patient's activities of daily living (ADL) status and self-sufficiency have declined and deteriorated, respectively over the prior 90 days.  The patient fell at home, was found by son and taken to local hospital (not admitted).  The patient's cognitive and functional ability have also declined when compared to the previous UAS report.  

The hospital Discharge Summary "Statement of Medical Necessity for Increase" from the patient's treating nurse practitioner (NP) Sarkisyan were reviewed.  The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested PCA services 7 days per week, 24 hours per day (split shift).  This physician would agree that given the patient's reported general weakness and debility, the patient may benefit from additional safety monitoring.  However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   There has been a decrease in the patient's cognitive and functional ability which warrant an increase in PCA services.  Attention to the patient's functional needs are more appropriately provided and maintained by increasing PCA services to 12 hours/day, 7 days per week, for a total of 84 hours per week. 

From a physical medicine and rehabilitation perspective, PCA services level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week is not medically necessary.  However, increasing PCA services level 2; 12 hours/day, 7 days/week for a total of 84 hours/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 assistance services (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week services is not substantiated. 

However, increasing PCA services level 2; 12 hours/day, 7 days/week for a total of 84 hours/week is medically necessary.