Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, stroke with hemiplegia and glaucoma

Treatment: Personal care aide (PCA) level 2: 12 hours/day, 7 days/week, a total of 84 hours/week

The insurer denied coverage for PCA level 2: 12 hours/day, 7 days/week, a total of 84 hours/week.

The denial is overturned, in part.

This is an elderly patient with multiple medical problems including heart disease, stroke with hemiplegia and glaucoma. The patient lives with the spouse in a private residence. The patient has personal care aide (PCA) 6 hours/day, 7 days/week and the request is for 12 hours/day, 7 days/week, which is under review.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as severely impaired. The patient is totally dependent for much of the instrumental activities of daily living (IADLs) including meal preparation, ordinary housework, and shopping. The patient also requires maximal assistance for activities of daily living (ADLs) including bathing, personal hygiene, dressing, eating, bed mobility, locomotion, ambulation, and toilet transfer/use. The patient is frequently bladder and bowel incontinent. 

The patient's cognitive and functional ability are much the same when compared to the previous UAS report. In addition, the functional ability documented on the UAS report that was reported by the patient's family and as discussed by the treating provider are inconsistent with the functional ability as documented by the Rehabilitation and Nursing Center where the patient was a patient. According to the therapy notes, the patient was at the supervision level for locomotion and able to ambulate household distances (approximately 75 feet) with a rolling walker. 

The patient's clinical condition and functional ability are not at a level or unpredictable as to require the requested PCA level 2: 12 hours/day, 7 days/week, for a total of 84 hours/week. Based on the clinical records reviewed and including the therapy notes, increasing PCA to 9 hours/day, 7 days/week (total 63 hours/week) is clinically appropriate. This physician would agree the patient may require additional monitoring; particularly due to the cognitive status and falls risk. However, safety monitoring under Patient Care Services (PCS) does not include monitoring an individual (such as with dementia) when no other level I or level II PCS task is being provided. Based on the enclosed documents reviewed, attention to the patient's physical needs can be appropriately provided and maintained by the increasing PCA services to 9 hours/day, 7 days/week, totaling 63 hours/week. 

From a physical medicine and rehabilitation perspective, increasing PCA level 2: 12 hours/day, 7 days/week, for a total of 84 hours/week is not medically necessary. However, increasing PCA level 2: 9 hours/day, 7 days/week, for a total of 63 hours/week is medically necessary.

Based on the above, the insurer's denial must be overturned, in part. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for PCA level 2: 12 hours/day, 7 days/week, a total of 84 hours/week is not substantiated. However, increasing PCA level 2: 9 hours/day, 7 days/week, for a total of 63 hours/week is medically necessary.