Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular Disease.
Treatment: in Personal Care Aide (PCA) services for 12 hours a day, 7 days a week for a total amount of 84 hours per week.
The insurer denied: in Personal Care Aide (PCA) services for 12 hours a day, 7 days a week for a total amount of 84 hours per week.
The denial is: Overturned.

The patient is a female with medical history notable for hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side. The patient is currently receiving 7.5 hours per day, 7 days per week (total 52.5 hours per week) of level 2 personal care assistance. The patient and her care team requested an increase to 12 hours per day, 7 days per week (total 84 hours per week). This request was denied by the insurance plan, and this denial is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented times three, with modified independence in cognition. Short term recall is intact. From a functional standpoint, the patient requires total dependence for housework, managing finances, stairs, and transportation. She requires maximal assistance for meal preparation, managing medications, and shopping. For her activities of daily living (ADLs), she requires total dependence for walking and locomotion. She requires maximal assistance for bathing, hygiene, dressing upper/lower body, toilet transfer, toilet use, and bed mobility. She requires extensive assistance for eating. She has had increasing dependence on others for ADL's due to worsening balance and inability to walk. She had a transient ischemic attack (TIA) and had a decline in functional status at that time. She is frequently (daily) incontinent of urine, and continent of stool. She wears diapers for incontinence. Compared with a prior UAS, she showed a decline in functional status in walking and locomotion. A task tool associated with the most recent assessment recommended 52.5 hours per week to meet her personal care needs, which was unchanged from her prior assessment.

The health plan's determination is overturned.

The requested health service/treatment of increase in Personal Care Aide (PCA) services for 12 hours a day, 7 days a week for a total amount of 84 hours per week is medically necessary for this patient.
The patient has functional deficits across all domains and requires human assistance to complete all ADL's and Instrumental activities of daily living (IADLs). She has shown a decline over the past year. The patient's son has been filling in and helping to cover additional personal care needs not covered by the allotment of hours, but he is no longer able to do so. The patient cannot schedule all of her personal care needs into the 7.5 hours per day currently allotted. She has incontinence and requires assistance with toilet transfer and toilet use. Increased hours would not be intended solely for safety monitoring and security, but to help her complete these personal care tasks. Failure to meet these personal care needs would result in her staying in soiled diapers which could lead to skin breakdown and/or infection.