Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Nursing Services (including Private Duty Nursing)

Diagnosis: cerebrovascular accident (CVA)
Treatment: Personal Care Aide (PCA) Services
The insurer denied the Increase in Personal Care Aide (PCA) Services, Level 2: 8
Hours per Day, 7 Days per Week (Total of 56 Hours per Week). 
The health plan's determination is overturned.

The patient is a male with past medical history of hypertension, peripheral vascular disease, renal insufficiency, and cerebrovascular accident (CVA) who had been assigned PCA (personal care assistant) services 4.5 hours/day, 7 days/week, to total 31.5 hours/week based on assessment tool performed. The patient was assessed at maximal assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, walking, and locomotion. The patient was assessed at limited assistance with tasks of managing finances, personal hygiene, and dressing upper/lower body. With tasks of managing medication, bathing, and transfer toilet the patient was assessed at supervision only while set up only for task of phone use. The HELPS task tool assessed 20.0 hours of task assistance. The patient had assessment tool performed via telephone assessing the patient at maximal assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, bathing, dressing upper/lower extremity, walking, locomotion, and transfer toilet. The patient was assessed as independent with task of toilet use, bed mobility, and eating. The patient's HELPS task tool assessed 22.5 hours per week of needed assistance. The patient was admitted to the hospital with right sided weakness and numbness and was diagnosed with CVA. There was a request to increase PCA services and the patient had telephonic assessment tool performed assessing the patient at total assistance with task of ordinary housework while maximal assistance with tasks of meal preparation, managing finances, shopping, bathing, and dressing upper/lower body. The patient was assessed at extensive assistance with tasks of managing medication, stairs, transportation, personal hygiene, walking, locomotion, transfer toilet, toilet use, and bed mobility and set up for phone use. The patient was assessed at independent with task of eating. The Increase in PCA Services, Level 2: 8 Hours per Day, 7 Days per Week (Total of 56 Hours per Week) is medically necessary for this patient. The patient had CVA with right sided symptoms in mid-summer with subsequent assessment tool documenting increased need with multiple tasks. The patient requires assistance with unscheduled and unpredictable care needs over a continuum of time. These unscheduled needs involve tasks of walking, locomotion, transfer toilet and toilet use all of which the patient needs assistance with. The patient's PCP documented the medical necessity of an increase in PCA service hours. The assessment tool documented the patient needed weight bearing assistance and a personal care assistant for ambulation and all transfers. The HELPS task tool calculated double the amount of hours compared to previous but the plan did not double the PCA services hours per week. (which would calculate to be 63 hours/week). The patient requires safety monitoring and supervision to assure safe completion of one or more activities of daily living (ADL) and Instrumental activities of daily living (IADL) and the task based assessment tool does not reflect sufficient time for such supervision and safety monitoring. Personal care services are a medical necessity when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home. Therefore, the increase in PCA hours is medically necessary.