Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, cerebral infarction, hemiplegia and hemiparesis

Treatment: personal care aide (PCA) services, 12 hours per day, 7 days per week (total of 84 hours per week)
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The insurer denied coverage for personal care aide (PCA) services, 12 hours per day, 7 days per week (total of 84 hours per week)

The denial is overturned.

This case involves an elderly female with a request for additional hours of a personal care aide.  Comprehensive community health assessment report reported the patient was being reassessed for significant change in condition.  The patient was noted to not be able to give correct month or year and had been diagnosed with age-related cognitive decline.  The patient reported occasional sadness related to health conditions and was being treated for depression with medication management.  The patient required maximal assistance with meal preparation and phone use and total dependency on housework and managing medications.  The patient also required maximal assistance with personal hygiene, dressing upper body, bed mobility, and eating.  The patient required total dependency on dressing lower body, bathing, toilet use, and transferring on and off toilet.  It was reported the patient required an increase in assistance in the form of complete assistance with transferring from bed to wheelchair as well as bathing and toileting. The patient was seen for follow-up.  The patient was status post cerebral vascular accident (CVA) with left sided hemiparalysis.  The patient was at a nursing home until recently but was now at home.  The patient was alert and verbally interactive.  There were complaints of depression, anxiousness, and sleep difficulty.  Physical examination reported the patient was in a wheelchair and had a left hemiparesis.  The patient was recommended for medication management and labs.  It was noted the patient needed full care for all activities of daily living.  The patient had an aide and lives with daughter and son.  Initial adverse determination letter reported that the patient had been approved for a personal care aide for 9 hours a day, 7 days/week.  The request for additional hours 12/day was denied.  Appeal letter reported the patient's condition had changed given that she suffered a stroke approximately 3 months ago.  The patient's ability to carry out her activities of daily living was markedly impaired in relation to her previous status when she was receiving 9 hours a day of service.  It was reported the patient needed assistance with turning in bed, eating, incontinence, moving in the Hoyer lift, and all other movement.  Final adverse determination letter reported the previous modification from 12 hours to 9 hours/day was upheld.  It was noted that the patient was able to receive assistance from her son and daughter.  The patient had a personal emergency response system in case of emergency.  The patient also had hospital bed, lift, wheelchair, and incontinent supplies.  Time had been allotted for household work, laundry, and meal preparation.  Follow-up reported the patient had increased anxiety and requested a psychiatric referral.  Letter from the patient's provider reported the patient had a stroke and was now paralyzed on the left side and needed more assistance with all activities of daily living.  It was reported that the patient's daughter could not operate devices or change her diapers.  Attorney letter reported the patient had significant change in status to include cognitive decline due to stroke.  The patient required maximal assistance for all task to include toileting, bed mobility, and transferring.

The patient is an elderly female status post cerebral vascular accident (CVA) with left sided hemiparalysis.  The patient had been approved for a personal care aide for 9 hours a day, 7 days/week.  The request for an additional 3 hours per day was denied.  It was noted that the recent change in the patient's condition warranted the additional 3 hours per day given needs to include toileting, bed mobility, and transferring. Given the patient's physical and cognitive decline after the stroke and increase in hours would be appropriate. Family members have been noted as unable to properly assist in transferring and assisting in toileting needs for the patient. An extension from 9 to 12 hours of personal care aide 7 days/week would be medically necessary given the change in condition. 

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

The insurer's denial of coverage for personal care aide (PCA) services, 12 hours per day, 7 days per week (total of 84 hours per week) is overturned. Medical Necessity is substantiated.