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202305-162936

2023

Centers Plan for Healthy Living

Managed Long Term Care

Cardiac/ Circulatory Problems

Home Health Care

Medical necessity

Overturned

Case Summary

Diagnosis: Kidney disease, hypertension and peripheral vascular disease

Treatment: Personal care aide (PCA) level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week

The insurer denied coverage for PCA level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week

The denial is overturned.

This is an elderly male with chronic medical problems including kidney disease, hypertension and peripheral vascular disease. According to his treating physician, the patient is terminally ill, enrolled in a Visiting Nurse Service (VNS) hospice program (nursing facility) and reportedly has less than 6 months to live. Upon his return home, the insurer indicated it will approve PCA level 2: 10.5 hours/day - 7 days per week for a total of 73.5 hours per week. The request is for personal care aide (PCA) level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week.

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as severely impaired. He is totally dependent for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. He is also totally dependent for bathing, personal hygiene, dressing, bed mobility, locomotion and toilet transfer/use. He is incontinent of bladder and bowel. The patient is essentially bed bound and non-ambulatory.

The patient's functional ability has decreased when compared to the previous UAS report. He is currently a resident in a skilled nursing facility. According to the notes from the nursing facility, the patient "is totally dependent on the staff for all aspects of Activities of Daily Living (ADL) care." The patient's medical condition, severe cognitive deficits and physical limitations are at the level or unpredictable as to require the requested PCA level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week.

Based on the records reviewed, a live-in PCA is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. The patient's functional needs would be more appropriately provided and maintained with the requested PCA level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week.

From a physical medicine and rehabilitation perspective, personal care aide (PCA) level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week is 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 aide (PCA) level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week is substantiated.

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