Appeal type: Medical necessity
Decision: Overturned

Central Nervous System. 
Nursing Services (including Private Duty Nursing). 

Diagnosis: Cerebrovascular Accident. 
Treatment: Personal Care Services. 

The insurer denied Increase in Personal Care Services to 24 Hours per Day (Split-Shift), 7 Days per Week: Total of 168 Hours per Week. The health plan's determination is overturned. 

The patient is a male with past medical history of cerebrovascular accident (CVA) with hemiplegia, immobility, hyperlipidemia, peripheral vascular disease, hypertension, atrial fibrillation, urinary incontinence, fecal urgency, DM (diabetes mellitus) type 2, and basal cell cancer who had been assigned PCA (personal care assistant) services 12 hours/day, 7 days/week, to total 84 hours/week. There was a request to increase PCA services to 24 hours/day, split-shift, to total 168 hours/week. The patient had assessment tool performed assessing him at total assistance with task of meal preparation, ordinary housework, and stairs while maximal assistance with tasks of shopping, bathing, dressing upper/lower body, transfer toilet, and toilet use. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, transportation, personal hygiene, and bed mobility while limited assistance with task of eating. The assessment tool noted the patient lived with his wife who also had PCA services 12 hours/day, 7 days/week. 

The Increase in Personal Care Services to 24 Hours per Day (Split-Shift), 7 Days per Week: Total of 168 Hours per Week is medically necessary for this patient. 
The patient has history of CVA with immobility and hemiparesis. The patient requires some level of assistance with all activities of daily living (ADL)/ Instrumental activities of daily living (IADL) per assessment tool performed. The patient has unscheduled and unpredictable care needs over a continuum of time as well as the need for turning and repositioning every 2-3 hours. The assessment tool noted "PCA reports that member is non ambulatory with minimal movement to lower extremities. Member is able to move right arm, right shoulder, wrist and hand/fingers. PCA reports limited mobility to left arm. Member needs assistance with bed mobility and must have frequent position changes while in bed, member is able to transfer with one person assistance with standing and pivot". In addition, the assessment stated "member reported episodes of incontinence mostly at night time. He reported he is unable to wait long when he has urge to urinate and does not walk, uses urinal and incontinence briefs. A RN (registered nurse) instructed PCA in pressure ulcers prevention: to keep skin clean and dry, to use barrier creams and briefs appropriately; to change briefs timely; to keep sheet wrinkles free; to change body position every 2-3 hours". The patient has overnight needs that would not allow a PCA to obtain at least five hours of uninterrupted sleep. Increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's PCA care needs cannot be met with equipment and supplies alone. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home. Medical necessity is defined as medical care and services that are necessary to prevent, diagnose, correct, or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity or threaten some significant handicap.
Therefore, the Increase in Personal Care Services to 24 Hours per Day (Split-Shift), 7 Days per Week: Total of 168 Hours per Week is medically necessary for this patient.