Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident
Treatment: Increase Personal Care Aide Level II PCS Level II Basic to 24 Hours Per Day - Split Shift
The insurer denied the Increase Personal Care Aide Level II PCS Level II Basic to 24 Hours Per Day - Split Shift
The denial is overturned. 

The patient is a male with conditions including status post CVA (cerebrovascular accident) with right-sided hemiparesis, ESRD (end-stage renal disease), DM (diabetes mellitus), HTN (hypertension), GERD (gastroesophageal reflux disease), and non-pressure foot ulcer. The patient is wheelchair bound. He lives in an apartment with a friend and health care provider. He does not receive informal support. The patient is appealing denial of 24 hours per day, split shift, PCA (personal care aide) services. The patient was approved for 70 hours per week.

Assessment performed showed minimally impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with bathing, walking, locomotion, and toilet use; extensive assessment with managing finances and medications, personal hygiene, dressing, toilet transfer and bed mobility; and limited assistance with phone use and eating. The patient uses wheelchair and scooter for locomotion. He is occasionally incontinent of bowel and bladder. He was hospitalized for right 5th toe infection. He was admitted after a fall. He was admitted with chest pain.

A letter dated from the provider recommends increase in PCA (personal care aide) hours due to chronic conditions, poor functional status, occasional inability to effectively communicate, and assistance with ADLs (activities of daily living) as already accounted for in the previous assessment. Statement from NY (New York) states the patient's multiple chronic and deteriorating conditions meet the need for 24 hour split shift care. It notes that the patient requires maximal or extensive assistance with unscheduled tasks. Night log shows the he requires regular turning overnight and assistance with changing diapers when the aide is not there.

Yes, the Increase Personal Care Aide Level II PCS Level II Basic to 24 Hours Per Day - Split Shift is medically necessary.
Medically necessary services are those which are:
1)	safe 
2)	effective
3)	generally accepted national standard of medical practice 
4)	not provided primarily for convenience of the patient or the practitioner 
5)	the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary, because it is consistent with generally accepted national standard of medical practice.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient was approved for 70 PAS per week.  The patient is appealing denial of 24 hour split shift PCA (personal care aide).

The patient has multiple chronic medical conditions, including hemiparesis, and he is wheelchair bound. He has several hospitalizations.  Assessment performed shows the patient requires extensive to maximal assistance with all ADLs (activities of daily living) and IADLs (instrumental activities of daily living) with the exception of phone use and eating, where he requires limited assistance.  He does not have informal support.  Appeal letters show the patient has poor functional status and deteriorating conditions.  He requires significant assistance including diaper changes and bed mobility that occur throughout the entire day.  The approved 70 PCA (personal care aide) hours per week are inadequate to meet the patient's needs with ADLs (activities of daily living) and IADLs (instrumental activities of daily living) as noted above.  The proposed increase PCA (personal care aide) to 24 hour split shift is medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.