Diagnosis: Spastic quadriplegia cerebral palsy, Chronic respiratory failure

Treatment: Personal care assistance (PCA) services, Level ll, 36 hours per week

The insurer denied coverage for personal care assistance (PCA) services, Level ll, 36 hours per week.

The denial is upheld.

This is a male patient with multiple medical problems including chronic respiratory failure on ventilator support via tracheostomy, congestive heart failure, dysphagia with a percutaneous endoscopic gastrostomy (PEG) tube and spastic quadriplegia cerebral palsy. The patient currently has around-the-clock private duty nursing care from a licensed practical nurse (LPN) 24 hours/day, 7 days a week, as well as personal care assistance (PCA) services 30 hours/week. A request was made for an increase of PCA services to 36 hours per week which was denied by the insurer.

The clinical records do not provide a compelling case for the requested additional services. The patient is severely debilitated with poor potential for any functional improvement. The primary reason for the request of additional services is reported difficulty turning the patient due to his heavy weight and thus, risk for pressure ulcers. However, according to a recent physician office visit note, there was "no skin breakdown" noted on this patient's physical exam. The current care hours can also be rearranged to better suit this patient's custodial care needs.

The Uniform Assessment System (UAS) report reflects the patient's debility level and service needs. The combination of the UAS and physician assessments support the extensive LPN/PCA services currently provided for the patient. However, the clinical records also demonstrate the provided quality of care, which is sufficient to meet the needs of this patient at this time.

From a physical medicine and rehabilitation perspective, the requested coverage for PCA services Level ll, 36 hours per week is not medically necessary.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. Considerations included the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations.

Based on the above, the medical necessity for PCA services, Level ll, 36 hours per week is not substantiated. The insurer's denial should be upheld.