Diagnosis: Hypertension, prostate cancer, heart disease
Treatment: Personal care aide 144 hours per week, consumer direct, 1 client
The insurer denied coverage for personal care aide 144 hours per week, consumer direct, 1 client.
The denial is upheld.

This is a geriatric patient with diagnoses that include hypertension, prostate cancer, and heart disease. The patient is also legally blind due to bilateral chronic glaucoma. The patient lives with daughter and her family. The patient is approved for Personal Care Aide (PCA) 84 hours per week, and the patient is requesting PCA 144 hours per week, consumer direct, 1 client.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as minimally impaired. The patient requires maximal assistance for bathing and lower body dressing. Extensive assistance is needed for personal hygiene, upper body dressing, locomotion, ambulation (uses a cane) and toilet transfer and use. The patient is occasionally incontinent of bladder and continent of bowel. The patient is otherwise independent with bed mobility and limited assistance for eating. There have been no falls, change in activities of daily living (ADL) status or self-sufficiency over the prior 90 days. The patient's medical condition, functional ability and mobility are not at the level as to require the requested PCA 144 hours per week. This physician would agree the patient (who lives with daughter and her family) may require additional 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 service tasks are being provided. Based on the records reviewed, the patient's health and safety are appropriately provided and maintained by the approved PCA 84 hours per week, consumer direct, 1 client.

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 144 hours per week, consumer direct, 1 client is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for personal care aide 144 hours per week, consumer direct, 1 client is not substantiated.