Diagnosis: Hypertension, diabetes, stroke, and dementia
Treatment: Personal care assistance (PCA) services, level II, 24 hours per day, 7 days per week (Monday through Sunday) (split shift)
The insurer denied coverage for PCA services, level II, 24 hours per day, 7 days per week (Monday through Sunday) (split shift)
The denial is overturned

This is an elderly male with multiple medical problems including hypertension, diabetes, stroke, and dementia. He lives with a non-relative in a private home. He is currently approved by the insurer for PCA 12 hours/day, 7 days/week (total 84 hours/week) and requesting a change to 24 hours per day, 7 days per week, (split shift).

According to the recent Uniform Assessment System (UAS) report, the patient's cognitive status is described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." Instrumental Activities of Daily Living (IADL) range from total dependence to maximal assistance. Functionally, he requires maximal assistance for bathing, lower body dressing, ambulation, locomotion, and toilet transfer/use. Extensive assistance is needed for personal hygiene, upper body dressing, bed mobility and eating. He is essentially bed/wheelchair bound. He requires frequent bed repositioning for skin breakdown prevention; particularly since he is frequently bowel and bladder incontinent. The patient's declining and deteriorating activities of daily living (ADL) status and self-sufficiency are at a level and unpredictable as to require PCA services 24 hours/day, 7 days/week (split shift). Based on the records reviewed, the PCA is unlikely capable of providing for the patient's functional needs with the ability to obtain uninterrupted 5 hours of sleep. As a result, the patient's health and safety would be more appropriately provided and maintained at home with PCA services 24 hours/day, 7 days/week split shift.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.

From a physical medicine and rehabilitation perspective, PCA services, level II, 24 hours/day, 7 days/week (Monday - Sunday) (split shift) are medically necessary.

Based on the above, the insurer's denial must be overturned. 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 (PCA) services, level II, 24 hours per day, 7 days per week (Monday through Sunday) (split shift) is substantiated.