Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke
Treatment: Personal Care Worker (PCW) services 6 days/week, 12 hours/day and 1 day/week, 12 hours/day of Consumer Directed Personal Assistance Services (CDPAS) 84 hours/week, (split shift with mutual spouse)
The insurer denied coverage for PCW services 6 days/week, 12 hours/day and 1 day/week, 12 hours/day of CDPAS 84 hours/week, (split shift with mutual spouse).
The denial is overturned.

This patient has substantial functional impairment primarily due to a stroke and depends on caregiver assistance for all daily activities. The patient lives with her husband. She receives some informal help from her children, but mostly depends on personal care services (PCS) for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient and her husband had been receiving personal care services as a mutual case that totaled 24 hours/day split shift. The patient and her husband were each approved for 84 hours/week, 12 hours/day and so combined were receiving 24 hours of continuous services per day from two aides, each working a 12-hour shift per day. Services are provided as Personal Care Worker (PCW) services and Consumer Directed Personal Assistance Services (CDPAS). The insurer decided to reduce services to 24 hours/day live-in as mutual services for the patient and her husband, still provided as PCW services and CDPAS. The patient appealed the decision, which was denied. An external appeal was requested.

The most recent Uniform Assessment System (UAS) report was reviewed. The functional status report for IADLs indicated patient was totally dependent for meal preparation, ordinary housework, shopping, stairs, transportation, equipment management; she needed maximal assistance for managing medications; extensive assistance for managing finances, phone use. For ADLs, it was noted the patient did not walk and was not transferred to the toilet during entire period. She was totally dependent for bathing, dressing lower body, locomotion, toilet use; she needed maximal assistance for dressing upper body, bed mobility; extensive assistance for personal hygiene; limited assistance for eating. No change in ADLs were noted from the previous UAS compared to the recent one.

In order to decide that the patient can safely be managed with reduction of PCS, the insurer needed to determine that the patient's condition improved, or other services are available that would allow equivalent care with less PCW or CDPAS hours. The information provided for review does not demonstrate convincing evidence that the patient's condition has improved or that her care needs are less frequent to support reduction of PCS. The patient is totally incontinent of bladder and bowel, no improvement reported. In fact, the physician noted that after the stroke, the patient had awareness of when she needed to urinate or move her bowels but it was noted that she no longer is fully aware of her bladder and bowel function. She needs maximal assistance for bed mobility. Her ability to move is so limited that she needs a Hoyer lift for transfers in and out of bed. Timely and effective performance of these two ADLs (i.e. [that is], incontinence care and bed mobility) are essential to the patient's health and comfort. 

Therefore, it is medically necessary for the patient to have PCS, 24 hours/day continuous care split shift to help prevent adverse medical events. 

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for PCW services 6 days/week, 12 hours/day and 1 day/week, 12 hours/day of CDPAS 84 hours/week, (split shift with mutual spouse) is overturned. Medical necessity is substantiated.