Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident with hemiparesis.
Treatment: Personal care aide (PCA) level 2: 8 hours per day, 7 days per week- for a total of 56 hours per week.
The insurer denied the Personal care aide (PCA) level 2: 8 hours per day, 7 days per week- for a total of 56 hours per week.
The determination is overturned.

The patient has a past medical history of a cerebrovascular accident (CVA) with hemiparesis, gout, coronary artery disease, urinary incontinence, benign prostatic hyperplasia (BPH), and hypertension who had been assigned personal care assistant (PCA) services 6 hours/day, 5 days/week to total 30 hours/week based on an assessment tool. The patient was assessed at total assistance with the tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing finances and managing medication. With the tasks of stairs, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, and bed mobility the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene, dressing upper body, toilet use, and eating.
There was a request to increase the PCA services and the patient underwent a telephonic assessment tool assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing finances, managing medication, stairs, transportation, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility while limited assistance with task of eating. Notes from this assessment stated the patient lived with his spouse and required a walker for ambulation. In addition, notes from the telephonic assessment stated his wife reported the patient had functional decline due to weakness which affected his ability to perform personal hygiene, bathing, and using the toilet.
The insurer sent an initial and final adverse determination denial notice denying request to increase PCA services to 8 hours/day, 7 days/week, to total 56 hours/week. The denial further stated the request was not medically necessary and the patient did not meet criteria. In addition, the denial stated the patient lived with his spouse, lived downstairs from his child who was supportive and involved in his care, had time allotted for meal preparation, laundry, and housework, had a cane, shower chair, shower grab bar, walker, and incontinence supplies in the home to assist with the patient's personal needs, and additional hours were not provided when tasks were not being performed and for safety monitoring and supervision. The patient's provider appealed the denial decision and noted the patient had an initial CVA with hemiparesis which was worsening and recently had more urinary incontinence. The appeal also stated the patient had BPH with more difficulty with urination as well as nutritional deficiency. At issue is the medical necessity of  personal care aide (PCA) level 2: 8 hours per day, 7 days per week- for a total of 56 hours per week.
The patient had documented worsening in his physical functioning according to the patient's primary care physician (PCP) and wife. In addition, the telephonic assessment noted an increase in assistance needs with phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, and toilet use but did not account for this increase need in assistance with additional PCA hours. The earlier assessment noted the patient was able to ambulate with a quad cane while the later assessment noted the patient required a walker with support of caregiver. The patient requires assistance with unscheduled and unpredictable care needs of toileting and incontinence care which require assistance as well with locomotion and walking. The insurer did not develop a plan to meet these unscheduled and unpredictable care needs. The patient requires at least limited assistance with all activities of daily living (ADLs) /instrumental activities of daily living (IADLs) and would need PCA in the hours when he does not have informal help. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. 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 8 hours/day, 7days/week, to total 56 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.