Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hemiplegia related to cerebrovascular accident CVA
Treatment: Personal Care Worker (PCW) Service 7 days per week, 12 hours per day; 84 hours per week
The insurer denied Personal Care Worker (PCW) Service 7 days per week, 12 hours per day; 84 hours per week.
The health plan's determination is overturned.

The patient is a female with a medical history notable for prior cerebrovascular accident (CVA) with resulting hemiplegia, seizures, urinary incontinence, osteoporosis and a history of falls with fracture. The patient is currently receiving 6 hours per day, 7 days per week (42 hours per week) of personal care services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week). 

A letter of advocacy from the patient's legal team describing their view in the appeal was provided and reviewed in detail.

A letter of medical necessity for this appeal was provided by the treating physician. The physician noted that the patient had a fall resulting in a hip fracture that caused long term challenges to the patient's functional status. Her ability to perform transfers has declined since the fall. She requires assistance with all activities of daily living. Her family has been paying for an additional 6 hours per day to meet her needs, including her unscheduled and continuous care needs which cannot be adequately covered in the time allotted.
The patient's power of attorney (POA) and proxy feel that the health care plan's decision is incorrect for several reasons. The patient has not had an in person assessment in over two years and was recently in a nursing facility for 9 months. She is now in a new environment with new challenges. She also states that the social worker and physical therapist at the nursing facility had indicated to her that the patient would require more home health service hours to meet her needs. 

The outpatient office visit notes, physical therapy notes and skilled nursing facility rounding notes were reviewed. They note that the patient requires substantial to maximal assistance for toileting, toilet transfers and partial to moderate assistance for transfers (lying to sitting, sitting to standing, bed-to-chair).
The most recent Uniform Assessment System (UAS) that was available was reviewed and showed that the patient showed modified independence with cognition. She required maximal assistance for housework, meal preparation, transportation, and shopping. She required limited assistance for managing medications. For her activities of daily living (ADL's), she required extensive assistance for bathing, dressing lower body and toilet use. She required limited assistance for hygiene, dressing upper body, locomotion, toilet transfer, bed mobility and eating. She was infrequently incontinent of urine and continent of stool. A task tool associated with the assessment recommended 28.3 hours per week for her personal care needs.

The patient's team of physician's attested that her current allotment of personal care hours is insufficient to meet her needs. She has had a steady decline in function, owing to her history of CVA, falls with resulting fracture, pain and mobility problems. The patient also has worsening dementia and increased incontinence. The UAS was performed over 2 years ago and clearly does not reflect her current clinical state and functional status. Her cognition has declined. She has more urinary incontinence than was previously noted. Even at the time of the last assessment, she required extensive assistance for toileting. The notes from her stay at the nursing facility indicate she requires even more help for toileting at this point. Her functional needs for toileting coupled with her urinary incontinence make it very challenging to complete all personal care tasks in a scheduled manner. Besides needing help with more functional tasks, she is also performing them slowly due to her comorbid conditions.