Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic Brain Injury
Treatment: personal care assistance for a total of 42 hours per week
The insurer denied the personal care assistance for a total of 42 hours per week
The determination is overturned.


The patient has a past medical history of right hemiplegia and hemiparesis with a history of a traumatic brain injury from a gunshot wound. The patient also has a history of hypertension. The patient had been assigned personal care assistant (PCA) services 24 hours/week. The patient's primary care physician (PCP) provided a letter noting that the patient lived alone in his own apartment and had cognitive and mobility impairments. The PCP note also stated the patient's aide services were not sufficient to meet his care needs.
The patient underwent a telephonic assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs and transportation. The patient was assessed at limited assistance with tasks of managing finances, managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, and bed mobility while supervision only with task of toilet use. With the task of eating the patient was assessed at independent. Notes from the  assessment stated the patient had no informal help.
The patient's legal advocate provided a letter stating the patient had suffered several falls trying to clean his apartment, run errands, and was not able to prepare any meals on his own forcing him to leave his home to purchase food. This letter also stated the patient currently had an aide who was not able to help the patient with all of the tasks and activities of daily living (ADLs) s that the patient needed assistance with. Lastly, the letter from the patient's legal advocate stated the patient had no informal caregivers available. The insurer sent final adverse determination denial notice denying request to increase PCA services stating the request was not medically necessary and the patient's PCA assistance under the last authorization or reauthorization was enough to meet his needs. The patient's legal advocate provided another letter requesting an external appeal of denial decision. The patient appealed the denial decision.
The services are medically necessary. The patient has hemiparesis with documented assistance needs with all ADLs/ instrumental activities of daily living (IADLs). The patient requires more assistance to complete ADLs/IADLs and has no informal support. The patient's PCP provided documentation of needed increase in PCA services as medically necessary. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met solely with medical supplies and adaptive equipment. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 42 hours/week are medically necessary for this patient. 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.