Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, asthma, hypertension, stroke.
Treatment: Increase Consumer Directed Personal Assistance to 24 hours per day, 7 days per week, live-in.

The insurer denied the request for an increase in Consumer Directed Personal Assistance to 24 hours per day, 7 days per week, live-in.  The insurer approved Consumer Directed Personal Assistance total 70 hours per week 

The denial is overturned.

The patient is a senior female. Her conditions include heart disease, asthma, hypertension and stroke.  She lives alone in a three bedroom apartment. 

UAS (Uniform Assessment System) evaluation notes the patient has minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, housework, shopping, bathing, dressing, walking, locomotion, toileting; and extensive assistance with managing finances and medication, phone use, personal hygiene, bed mobility and eating. She is wheelchair bound.  A Hoyer lift is required to get the patient from her bed to a wheelchair.  She has DME (durable medical equipment) including a hospital bed with PERS (personal emergency response system), shower grab bars, BP (blood pressure) machine, bedside commode, incontinent supplies, wheelchair, walker, and cane.  She is frequently incontinent of bowel and bladder.  A statement from the nursing home notes the patient was admitted with diagnoses of CVA (cerebrovascular accident), COPD (chronic obstructive pulmonary disease) and anxiety.  The patient has periods of confusion.  She requires high level care, including two person assistance with transfers and ambulation.  She is incontinent of bowel and bladder.  As such, an increase Consumer Directed Personal Assistance to 24 hours per day, 7 days per week, live-in is requested.

Yes, the Increase Personal Care Assistance to 24 hours per day, 7 days per week, live-in is medically necessary.  The approved Consumer Directed Personal Assistance total 70 hours per week is insufficient to meet this patient's needs for assistance with ADLs / IADLs (activities of daily living / instrumental activities of daily living). 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding.  

This patient has multiple chronic conditions including recent stroke. She is wheelchair bound.  UAS (Uniform Assessment System) evaluation shows the patient requires extensive assistance to total dependence with all ADLs / IADLs (activities of daily living / instrumental activities of daily living).  A Hoyer lift is used for transferring the patient from her bed to a wheelchair.  She is incontinent of bowel and bladder.  Nursing home statement notes the patient requires two-person assistance with transfers and ambulation and needs 24-hour care when returns to home.  Information provided shows that the patient is wheelchair bound and requires significant assistance with all ADLs (activities of daily living).  The approved Consumer Directed Personal Assistance total 70 hours per week is insufficient to meet this patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living).  The requested increase to PCA (personal care assistance) 24 hours per day, 7 days per week, live-in is appropriate and medically necessary.