Diagnosis: Coronary artery disease, hypertension and osteoarthritis

Treatment: personal care assistant (PCA) services to 24 hours/day split-shift service

The insurer denied coverage for personal care assistant (PCA) services to 24 hours/day split-shift service

The denial is modified.


This is an elderly patient with coronary artery disease, hypertension and osteoarthritis. She lives alone in a 1-bedroom apartment. The insured approved PCA services 12 hours/day, 7 days/week and the request is for 24 hours/day split shift.

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as minimally impaired. She is totally dependent to maximal assistance for her Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. Extensive assistance is needed for bathing, dressing, personal hygiene, locomotion, ambulation and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. Limited assistance is needed for bed mobility and eating. She reportedly fell and loss consciousness at her grandson's house 1 month prior. There were no reported falls in her home over the prior 90 days. Her functional ability has decreased compared to the previous UAS report. The patient's cognitive and functional deficits are not at a level or unpredictable as to require the requested PCA services 24 hours/day (split shift). Based on the records reviewed, a live-in PCA is more appropriate as they are likely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home by increasing PCA services to 24 hours/day, 7 days/week (live-in).

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 an increase in personal care assistant (PCA) services to 24 hours/day split-shift services is not substantiated. However, increasing PCA services 24 hours/day (live-in) is medically necessary.