Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke/cerebral vascular accident
Treatment: Personal Care Services (PCS) for 10 hours a day, 7 days a week for a total of 70 hours 
The insurer denied Personal Care Services (PCS) for 10 hours a day, 7 days a week for a total of 70 hours.
The denial is overturned.

The member is an elderly female with a history of general debility due to stroke/cerebral vascular accident (CVA) with left hemiplegia and trigeminal neuralgia. The request was for 
Personal Care Assistance through Home Health care (Level 2) to be increased from 45 hours per week (7 hours per day, 5 days per week plus (+) 5 hours a day, 2 days a week) based on Uniform Assessment System (UAS) of 9 months ago, to 70 hours per week (10 hours per day, 7 days per week) based on Uniform Assessment System of 6 months ago. The health plan denied the request because she is alert and oriented to name and place although forgetful, required limited help with eating, while continuing to need help (extent not defined) with preparing meals, housework, laundry, shopping, bathing, dressing, toileting, personal hygiene, bed mobility. The management of behaviors and medical conditions are not needs that can be met by using personal care assistance and are outside the aide's scope of practice. The additional hours requested are because of her chronic medical conditions, and to help with her activities of daily living (ADLs) as she is moderately impaired cognitively with decisions consistently poor or unsafe and supervision required at all times, requires extensive assistance for phone use, personal hygiene, upper body dressing, walking, toilet transfer, toilet use, bed mobility, eating; requires maximal assistance for managing medications, bathing, lower body dressing, locomotion, and requires total dependence for meal preparation, housework, managing finances. She is also incontinent of bowel and bladder. She lives alone in a 3-bedroom apartment, is not safe, and is a risk of falls. A review of the records showed that the member has multiple chronic medical conditions including cerebral vascular accident with hemiplegia, several falls, recurrent urinary tract infection, trigeminal neuralgia, hyperlipidemia, ASD (atrial septal defect), and chronic obstructive pulmonary disease (COPD). 
Uniform Assessment System-New York (UAS-NY) evaluation of 6 months ago showed that she is minimally impaired cognitively; requires limited assistance for eating; extensive assistance for managing finances, managing medications, phone use, personal hygiene, walking, locomotion, toilet transfer, toilet use, bed mobility; maximal assistance for meal preparation, shopping, stairs, transportation, bathing, upper/lower body dressing; and total dependence for housework, while also incontinent of bowel and bladder. She lives alone in a 3-bedroom apartment. 

The requested health service is medically necessary. 

The requested increase for Personal Care Assistance through Home Health care (Level 2) from 45 hours per week (7 hours per day, 5 days per week + 5 hours a day, 2 days a week) based on Uniform Assessment System (UAS) of 9 months ago to 70 hours per week (24 hours per day, 7 days per week) is medically necessary because based on the most recent Uniform Assessment System of 6 months ago in which she is minimally impaired cognitively; requires limited assistance for eating; extensive assistance for managing finances, managing medications, phone use, personal hygiene, walking, locomotion, toilet transfer, toilet use, bed mobility; maximal assistance for meal preparation, shopping, stairs, transportation, bathing, upper/lower body dressing; and total dependence for housework, while also incontinent of bowel and bladder. The reason for denial by the health plan as stated in the clinical information above, does not align with her disability features as stated in the Uniform Assessment System of 6 months ago as stated above. Therefore the 70 hours per week (10 hours per day, 7 days per week) based on the most recent Uniform Assessment System should be approved.