Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gait Abnormalities, Incontinence

Treatment: Increase in Personal Care Aide services from 7 days per week 6 hours per day (42 hours per week) to 7 days per week 12 hours per day (84 hours per week)

The insurer denied coverage for Increase in Personal Care Aide services from 7 days per week 6 hours per day (42 hours per week) to 7 days per week 12 hours per day (84 hours per week)

The denial is overturned

This case pertains to a patient with diagnoses of constipation, abnormalities of gait and mobility, hypertension, mixed incontinence, gastroesophageal reflux disease, fecal urgency, muscle weakness, hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, history of falling, and difficulty walking. The patient's medications include aspirin, atorvastatin, gabapentin, hydralazine, pantoprazole, and senna. 

The patient attended physical therapy. The patient complained of muscle weakness and gait abnormality. The patient has a history of a cerebral vascular accident (CVA) with left hemiparesis three years prior. Evaluation showed overall decrease in functional status. 

The provider sent a undated letter noting the patient needed an increase in hours due to their deteriorating physical health and functional status based on clinical findings. The patient is a fall risk and needs increased supervision. The patient uses the restroom frequently. The patient wears diapers and requires multiple daytime and nighttime changes of soiled diapers and linens to prevent skin irritation and rash. 

A letter was sent to the patient to notify them that the appeal had been denied. The decision to keep the personal assistance hours at 42 hours per week was upheld. 

The patient is mildly cognitively impaired. The patient has not had any hospitalizations or falls within the 90 days prior to the assessment. The patient lives in a 2 bedroom, 2 family house with connecting stairs leading to the 2nd floor where their son resides with his wife and minor children. The patient ambulates utilizing a quad cane with hands-on assistance. The patient attends physical therapy two days a week. The patient requires maximal assistance with meal preparation, housekeeping, shopping, and bathing. The patient requires extensive assistance with personal hygiene, dressing, toilet transfers, and toileting. The patient requires limited assistance with ambulation, bed mobility, and eating. The patient is frequently incontinent for bladder and infrequently incontinent for bowel. 

The provider notes the patient has frequent restroom use during the day and at night. This should be increased to at least seven times a day. The son notes that he and his brother both work and are not available to assist the patient. Due to the patient's left sided hemiparesis and requiring hands on assistance with ambulation and need for extensive assistance with toileting, it is appropriate for 12 hours per day, 7 days per week. The decision is overturned to allow for 84 hours per week of personal assistance services (PAS). 

Based on the above, the insurer's denial must be reversed. 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 an increase in Personal Care Aide services from 7 days per week 6 hours per day (42 hours per week) to 7 days per week 12 hours per day (84 hours per week) is substantiated.