Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident; Hemiplegia; Dementia. 
Treatment: Personal Care Assistance (PCA) services. 

The insurer denied coverage for personal care assistance (PCA), 70 hours per week. 
The denial is overturned. 

This male patient has a medical history including cerebrovascular accident (CVA), left sided hemiplegia, hypertension, osteoarthritis, chronic pain, urinary incontinence, and dementia. 

He receives personal care assistance (PCA) services of 8 hours a day, 6 days a week and 7 hours a day, 1 day a week (total of 55 hours a week). His advocate has requested an increase of PCA services to 10 hours per day, 7 days per week for a total of 70 hours per week, which was denied. 

The most recent Uniform Assessment System (UAS) provided indicates the patient was totally dependent or needed maximal assistance for most IADLs, except medication management (extensive assistance). The patient's ambulation is very limited, and he is dependent on others for wheelchair transport. All of his activities of daily living (ADLs) required maximal or extensive assistance. His partner reported that the patient had physical and occupational therapy since his CVA (a stroke), and though some improvement was noted, his overall mobility has declined.

Stroke is often a life changing medical event, as many stroke survivors have various residual neurologic deficits. The decline in function can result in secondary medical problems affecting the physical, cognitive and emotional status of the affected person. The UAS and the letters from the physician and patient's partner provide information identifying some of the sequelae from the stroke that appear to have produced the greatest burden on the patient and his family/caregivers. 

The patient has very limited mobility and he is frequently incontinent. Both conditions increase risk for pressure ulcers. It is not known how frequently the partner provides incontinence care and repositioning through the night. Preventing skin damage from incontinence (e.g. dermatitis, fungal infection) and pressure (pressure ulcers) should be a priority in the patient's care plan. Pressure ulcers can result in necrosis and severe infection (e.g. osteomyelitis, sepsis), and may require surgical intervention. 

Regarding falls, the patient's mobility is very limited, but he may still try to get up and walk unassisted. This was noted in the UAS (due to his impaired memory and poor safety awareness he thinks he can walk without assistance). Stroke is associated with increased risk of falls. The patient has other risk factors, including arthritis, poor balance, cognitive impairment, incontinence, use of medications associated with fall risk (e.g. antidepressant). The patient is also taking an anticoagulant so there is an increased risk of bleeding from falls. When older people fall there is increased risk of serious injury (e.g. fractures, head trauma), significant morbidity and increased risk of death. 

Assistance from informal caregivers is voluntary as per NYS regulations for PCA services. The partner (informal caregiver) is requesting additional help for services the patient needs, (i.e. transfers, toileting) that she is unable to provide. When informal caregivers are unable to provide necessary care on a consistent basis when needed, then PCA services are indicated to provide assistance with all ADLs during hours when care is needed and not provided by informal caregivers. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for Personal Care Assistance (PCA) services at 70 hours per week (10 hours per day, 7 days per week) is substantiated. The insurer's denial should be overturned.