Diagnosis: End stage renal disease, diabetes, cataracts, dementia
Treatment: Consumer Directed Personal Care Assistance Services (CDPAS), 8 hours per day 5 days per week (Monday through Friday) and Personal Care Assistance services (PCA), Level ll, 8 hours per day 2 days per week (Saturday, Sunday), total of 56 hours per week
The insurer denied coverage for consumer Directed Personal Care Assistance Services (CDPAS), 8 hours per day 5 days per week (Monday through Friday) and Personal Care Assistance services (PCA), Level ll, 8 hours per day 2 days per week (Saturday, Sunday), total of 56 hours per week.
The denial is upheld.

This is a geriatric patient with medical problems that include end stage renal disease (dialysis), diabetes, cataracts, and dementia. The patient lives with the spouse in a private residence. The patient is approved for Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week and is requesting additional Personal Care Assistance (PCA) level ll; 8 hours per day, 2 days per week (56 hours per week total).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is "modified independent." Performing Instrumental Activities of Daily Living (IADL) tasks varies from limited to maximal assistance. The spouse prepares the meals and informal care is also provided by the sister. The patient requires extensive assistance for bathing, lower body dressing and toilet use. Only limited assistance is needed for upper body dressing and general mobility (locomotion and ambulation). The patient is otherwise independent for bed mobility and eating. The patient is frequently incontinent of bladder and continent of bowel. There has been no change in Activities of Daily Living (ADL) status or falls over the prior 90 days. The clinical condition and functional deficits are not at a level or unpredictable as to require additional PCA, Level ll, 8 hours/day 2 days/week (Saturday, Sunday), total of 56 hours/week. The patient's daughter indicates the patient does not receive any paid caregiver care on the weekends. The patient has the informal care of the spouse and sister on the weekends. In addition, the currently approved CDPAS of 40 hours/week can be flexibly modified and extended over 7 days to better provide for the patient's health and safety in the home.

From a physical medicine and rehabilitation perspective, the requested CDPAS, 8 hours/day 5 days/week (Monday through Friday) and PCA, Level ll, 8 hours/day 2 days/week (Saturday, Sunday), total of 56 hours/week are 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 Consumer Directed Personal Care Assistance Services (CDPAS), 8 hours per day 5 days per week (Monday through Friday) and Personal Care Assistance services (PCA), Level ll, 8 hours per day 2 days per week (Saturday, Sunday), total of 56 hours per week is not substantiated.