Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Vascular Accident
Treatment: Personal Care Aide (PCA) Level 2 Services
The insurer denied Personal Care Aide (PCA) Level 2 Services. The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease, hypertension, vascular dementia, cerebrovascular accident (CVA) with hemiplegia, depression, incontinence of bowel, incontinence of bladder, constipation, vitamin B12 deficiency, gastroesophageal reflux disease (GERD), and osteoarthritis who had been in rehabilitation facility with plan to be discharged home. She underwent a telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, and shopping while maximum assistance with tasks of phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. There was a request to increase PCA (personal care aide) services and the patient underwent a telephonic assessment tool assessing the patient at total assistance for tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, bathing, dressing lower body, toilet use, and bed mobility while maximum assistance with tasks of phone use, personal hygiene, dressing upper body, and eating. The assessment stated tasks of walking, locomotion, and transfer toilet did not occur. A Note also stated the patient was bedbound and could not walk and could not be wheeled by others.

Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day, 7 Days per Week (Split Shift) for a Total Amount of 168 Hours per Week are medically necessary for this patient..
The patient has documented chronic and progressive medical conditions of vascular dementia, coronary artery disease, and osteoarthritis with documented decline in functional and cognitive status. The patient has hemiplegia secondary to a previous stroke. The patient has bowel and bladder incontinence. The patient's medical provider has documented the medical necessity of frequent turning and repositioning as well as frequent diaper changes as to prevent skin breakdown and pressure sores. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)/ Instrumental activities of daily living (IADL). The patient's son is no longer able to provide the same amount of informal help as previous. The patient's overnight care needs would not allow a PCA 5 hours of uninterrupted sleep. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day, 7 Days per Week (Split Shift) for a Total Amount of 168 Hours per 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 her own home.