Diagnosis: Dementia, cardiac disease and peripheral vascular disease
Treatment: Personal care assistant (PCA) services, Live-in, 24 hours per day, 7 days per week
The insurer denied coverage for Personal care assistant (PCA) services, Live-in, 24 hours per day, 7 days per week.
The denial is upheld.

This is an elderly male with multiple medical problems including dementia, cardiac disease and peripheral vascular disease. He lives alone in a private residence. The insurer approved Personal Care Assistant (PCA) services 12 hours/day, 7 days/week. The request is for PCA services, Live-in, 24 hours per day, 7 days per week.

The Uniform Assessment System (UAS) finalized report was reviewed. The patient's cognitive skills are described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." He is reportedly totally dependent for much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. He also reportedly requires maximal assistance for bathing, lower body dressing and toilet use. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, and toilet transfer. Limited assistance is reportedly needed for locomotion and ambulation. He is otherwise at the supervision level or independent for bed mobility and eating.

The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel. The patient's ADL (Activities of Daily Living) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. There have been no reported falls over the prior 90 days. The patient's cognitive and functional ability are much the same when compared to the prior UAS (Uniform Assessment System). The letter from the patient's treating physician describing his clinical condition and reported need for continuous human supervision, daily reminders and assistance in performing ADL was reviewed. The associated treatment notes were not included for review.

The patient may benefit from additional monitoring; particularly due to his reported declining cognitive status and wandering risk. However, safety monitoring under PCA (Personal Care Assistant) does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided. Based on the records reviewed as discussed above, attention to the patient's health, safety and physical impairments can be appropriately provided and maintained by the currently approved PCA services 12 hours/day, 7 days/week.

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 Assistant (PCA) services, Live-in, 24 hours per day, 7 days per week is not substantiated.