Appeal type: Medical necessity
Decision: Upheld

Diagnosis: spina bifida with paralysis.

Treatment: increase in Personal Care Aide (PCA) hours 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 (PCA) hours 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 upheld. 


The patient is an adult seeking coverage for an increase in personal care aide (PCA) hours from 7 days/week at 6 hours/day for 42 hours/week to 7 days/week at 12 hours/day for 84 hours/week.  At last reassessment there was a goal to remain safely at home without accidents, falls, or hospitalizations.  The patient was independent with cognitive skills for daily decision making.  The patient had no short-term or procedural memory problems.  There was no change in decision making as compared to 90 days prior.  

In an undated fair hearing request, it was stated that the patient required at least 12 hours of assistance per day for 84 hours/week.  The patient had spina bifida with paralysis of both lower limbs and was fully wheelchair-bound.  The patient utilized a urostomy bag and diaper. The patient had multiple VP shunts and a recent surgery for endoscopic ventriculostomy. The patient had hearing issues, vision issues, and dyslexia.  The patient had almost no sensation below the waist and needed an aide to constantly monitor for skin breakdown and ulcers.  The patient was now overweight and had very little upper body strength.  The patient could not transfer out of the bed without assistance.

Per the cited references, personal care services are the provision of some or total assistance with personal hygiene, dressing, and feeding and nutritional and environmental support.  The services must be essential to the maintenance of the patient's health and safety in their home, be ordered by physician or nurse practitioner, and be based on an assessment of the patient's needs for the service in accordance with guidelines.  The patient must have stable medical condition that does not require frequent medical or nursing judgment to determine changes in the patient's plan of care.  Allotment of time separate and apart from personal care tasks authorized is not required for safety monitoring.  In this case, the patient had a decline in ability to participate in activities of daily living.  The patient required limited to total dependence for all activities of daily living.  The patient had been receiving personal care aide services from 7 days/week at 6 hours a day for 42 hours a week.  The patient was recently authorized for an increase of hours of 70 hours/week.  The increased hours of 70 is reasonable for this patient.  The increased hours address the patient's decline in status.  The hours can also be utilized flexibly throughout the day to best meet the patient's daytime and evening needs.  Additional hours are not supported by the assessment.  

Based on the above, the insurer's denial must be upheld. The health care plan did 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 (PCA) hours 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 not substantiated.