Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CVA.
Treatment: personal care aide- 7 days x 12 hours x 2 shifts.
The insurer denied personal care aide- 7 days x 12 hours x 2 shifts.
The determination is overturned.


The patient has a past medical history of cerebral infarction, left hemiparesis, urinary incontinence, bowel incontinence, rheumatoid arthritis, fibromyalgia, gastroesophageal reflux disease (GERD), tobacco abuse, and morbid obesity who had a cerebrovascular accident (CVA) with subsequent transfer to a rehabilitation facility with a plan for discharge to home. The patient underwent a video assessment for personal care assistant (PCA) services assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing medication, stairs, shopping, transportation, equipment management, bathing, personal hygiene, dressing upper/lower body, locomotion, toilet use, and bed mobility. The tasks of walking and transferring the toilet did not occur and the patient was assessed under supervision with the task of eating, set up with the task of managing finances, and independent with phone use.
The insurer provided an initial adverse determination denial notice denying a request to increase PCA services to 2 x 12-hour split shift services, 7 days/week, to a total of 168 hours/week. The patient was discharged home from a Skilled Nursing Facility (SNF). The patient's current home health service provider noted the patient did not allow the aide to rest and sleep, was too difficult to manage by 1 aide, and required a schedule to be split into 2, 12-hour shifts because 1 aide cannot turn or change the patient because of her weight. The staff coordinator from home health services also noted the patient required a Hoyer lift that had access to use a commode and body mesh fold sling and that the patient needed to have a primary care doctor and therapies to be seen at the patient's home as the patient was fully bedbound. The home care agency provided a nighttime activity grid noting the patient was up overnight at least every 2 hours. The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating a sleep study was required to be reviewed. The insurer got a notice from the patient to request fewer diapers as she was only being changed 2 times per day.
The insurer provided a final adverse determination denying a request to increase PCA services stating there were no documented changes present that had affected the patient's environmental surroundings, social status, or functional abilities and the current hours could meet the patient's medical needs and support her activities of daily living. The patient had a follow-up visit with the primary care physician (or provider) (PCP) with an office visit note stating the patient was only being changed 2 times per day and was only eating 2 times per day and required more assistance with activities of daily living (ADLs). The patient's PCP provided a letter supporting the request for increased PCA services. The letter also stated the patient required an increase in changing of her diapers and an increase in positional changes. The provider noted the patient had findings of sacral pressure ulcers and moderately severe tinea infections of her sacral and cruris areas and that these findings were consistent with the patient remaining in a supine position for too long and also consistent with her possibly lying in wet diapers too long. The insurer's case notes stated they were looking for a new home care agency for the patient as the previous agency stated the patient was too difficult to deal with. The patient and her medical provider appealed the denial decision. The patient's healthcare advocate provided a letter requesting the initiation of an external appeal on behalf of the patient. At issue is the medical necessity of personal care aide- 7 days x 12 hours x 2 shifts medically necessary for this patient.
The services are medically necessary. There is documentation from the patient's medical provider of the medical necessity of split shift services. The patient has documented sacral ulcers and tinea infections. The patient requires turning and repositioning at least every 2 hours to prevent skin infection and to promote healing of sacral ulcers. The patient also requires frequent changing of soiled diapers to also prevent skin infections and promote the healing of sacral ulcers. The patient's assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are such that an aide would not be able to obtain at least 5 hours of uninterrupted sleep. The home care agency itself recommended split shift services as they felt the patient could not be cared for by one aide. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with the safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services, 7 days x 12 hours x 2 shifts, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in her own home.