Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular Accident (CVA)
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week 
The insurer denied: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week.
The denial is overturned.

The patient is a male with medical history notable for history of cerebrovascular accident, hemiparesis, neurogenic bladder and bowel, incontinence, aphasia, dysphagia, and unstageable pressure ulcer. The patient was approved for 8.5 hours per day, 7 days per week (59.5 hours per week) of personal care services. The patient and his care team requested an increase to 2-12 hours (split-shift) per day, 7 days per week (168 hours per week), and this request was partially denied by the insurance company. The insurance company did approve an increase to 10 hours per day, 7 days per week (70 hours per week). This denial is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented to person and place only, with 1/3 recall after 5 minutes. He was able to describe procedural tasks and identify an emergency plan. Cognition was classified as minimally impaired; however, he does have aphasia making him difficult to understand. From a functional standpoint, he requires total dependence for housework and transportation. He requires maximal assistance for meal preparation, managing finances and medications, and shopping. For his activities of daily living (ADL's), he requires total dependence for bathing, hygiene, dressing lower body, toilet transfer, and toilet use. He requires maximal assistance for dressing upper body and bed mobility. He has an indwelling Foley catheter due to neurogenic bladder. He is incontinent of stool with no control present. He requires enemas frequently due to constipation and will have stool leakage for prolonged periods following administration. There is a pressure ulcer on the sacrum. Compared with a prior UAS, the patient's functional status and cognitive status declined slightly.

The health plan's determination is overturned. 

The requested health service of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week is medically necessary for this patient.

The patient requires maximal assistance or total dependence for ADL's and Instrumental activities of daily living (IADL's). He has incontinence of stool and urine. He has a sacral pressure ulcer and requires turning and repositioning to promote healing. Nighttime care worker logs demonstrate that he cannot go longer than 2-3 hours between personal care tasks. Because his personal care needs are unscheduled, unpredictable, and occur around the clock, he requires 24 hour split-shift care. Failure to provide for his personal needs throughout all 24 hours of the day could result in worsening of his pressure ulcer and/or infection. Based on the information provided, a 24-hour live-in aide would not be appropriate because the aide would not routinely get at least 5 hours of sleep per night.