Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident (CVA), hypertension, hyperlipidemia, obesity, colon resection, and left ventricular (LV) dysfunction
Treatment: PCA (Personal Care Aide) hours 5 days per week, 10 hours per day

The insurer denied coverage for PCA hours 5 days per week, 10 hours per day.
The denial is overturned.

This patient has functional impairment associated with several medical conditions and requires assistance with most daily activities. The patient has developmental disability (extent of impairment is not fully described in available records), and her mother was her primary informal caregiver until last year when her mother died (as per UAS [Uniform Assessment System]). The patient has been receiving Personal Care Aide (PCA) services 5 days per week 6 hours per day. As per the sister's appeal letter, when the mother was alive, she assisted the patient when the aide was not present; as per UAS, the patient's sisters helped on weekends. The UAS describes the patient's home as an extension apartment (where she now lives alone) which is attached to one of her sister's homes. The other sister lives at another location. It appears that since their mother's death, the sisters have tried to help the patient when they can, but due to their own health issues and other responsibilities, it has been difficult for the sisters to be available for all the patient's care needs during non-PCA hours. 

The patient is intellectually and developmentally delayed. Her medical history includes hypertension, left ventricular (LV) dysfunction, status post (s/p) stroke (left sided neglect, weakness and limited use of left hand and leg) and surgery for colon cancer. The patient's informal support for her entire life was her mother. The mother died; date not noted in sister's letter, but as per UAS, mother died 2 weeks prior to the UAS.  

The patient has several medical conditions causing physical impairments which appear to have a significant adverse effect on her ability to perform daily activities independently. The available records indicate patient had cerebellar infarct affecting her balance. She also has left sided weakness with neglect and diminished hand-eye coordination. The patient also has symptoms of dysphagia following the stroke; precautions are necessary with oral intake, and supervision and cues are necessary for compliance with techniques for safe swallowing. 
 
The patient needs a caregiver present for all po (oral) intake including meals, snacks, medication. She is not able to safely go to the kitchen and retrieve a pre-prepared meal from the refrigerator, as she needs both hands for her walker; and even with a tray on her walker, there is risk of spilling items in transit to the table. The patient has signs of dysphagia (sequelae from stroke), with report of choking incidents (as noted by neurologist). She is at risk for aspiration and needs a caregiver present for supervision and cueing to remind patient of safety techniques for safe swallowing (e.g., take small bites; eat slowly).

MLTC (Managed Long Term Care) policy states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. The patient needs assistance with several ADLs that occur at unscheduled and recurring times of the day (e.g., toileting, incontinence care, transfer, walking, eating) for proper and safe completion of these activities. These care needs must be considered in the determination of the patient's personal care service hours.

Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have a caregiver present for a more extended period of time each day. The patient needs assistance for IADLs and ADLs including routine household tasks; preparation/service of all 3 meals and snacks; routine morning and evening ADLs (e.g., bathing, dressing, personal hygiene, supervision with eating); unscheduled and recurring activities, including toileting/incontinence care; mobility around the home (transfers, walking). Without adequate assistance, the patient is at risk for adverse health and safety events, including falls/injury; skin damage due to inadequate toileting/incontinence care; nutritional decline, aspiration.

Personal Care Aide services 50 hours per week was medically necessary.

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) hours 5 days per week, 10 hours per day is overturned. Medical Necessity is substantiated.