Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CVA with left hemiplegia; advanced dementia

Treatment: Personal Care Assistance Services 24 hours per day, 7 days per week (live-in or Split-shifts), total of 168 hours per week

The insurer denied coverage for Personal Care Assistance Services 24 hours per day, 7 days per week (live-in or Split-shifts), total of 168 hours per week. The denial was reversed.

This patient is a female has multiple medical conditions including: CVA with left hemiplegia in mid-2019, advanced dementia, incontinence.  The patient requires total care for all IADLs and ADLs. The patient had been living at home with her husband prior to stroke; both receiving personal care (PCA) services (mutual/shared services). The patient has been in a skilled nursing facility since mid-2019. She received physical and occupational therapy and demonstrated some improvement, though still needed substantial assistance for ADLs.  After discharge from Physical Therapy (PT) and Occupational Therapy (OT), orders were given for nursing rehab.  As per the daughter's comments, after PT/OT was stopped, the patient's level of function declined and patient currently cannot stand, transfer or walk.  She is dependent on caregivers for all daily activities/tasks.

The insurer denied increase of PCA services stating in the final adverse determination letter that the patient needs 2 person assist for transfers with Hoyer lift, and there are no informal caregivers who can reliably be present to be the second person assist when needed.

The patient requires total assistance for all IADLs and ADLs.  There are no behavioral problems reported, and the patient is small in stature (4 ft 11 in, 110 lb as per UAS); and so one aide should be able to manage ADL care.  The only issue in question is whether the patient requires 2 persons assist with Hoyer lift for transfers; and if so, are there voluntary caregivers who will provide the necessary assistance with the PCA.  The information received from the nursing home did not confirm whether 1 or 2 person assist was needed to transfer the patient via Hoyer lift.  Health care facilities often require Hoyer transfers to be performed by 2 people for safety.  As there is no recent documentation available confirming 1 or 2 person assist for Hoyer transfer, it must be assumed for the purpose of this review, and based on the insurer's denial letter that the patient needs 2 person assist for the Hoyer transfer.

The physician's letter was supportive of the plan to discharge the patient home with a home care aide and family support.  If the patient continues to be medically stable for discharge, then the other departments need to determine what is needed to provide a safe discharge plan.  With the knowledge that there are family members who will be available every day to provide assistance, the patient should be given the opportunity to return home, provided that the family receives the necessary education from the nursing home staff (which would need to include training for use of a Hoyer lift) and are willing and able to provide care on a consistent basis.  

With the knowledge that there are family members who are available to assist the patient at home, including one who will be living in the patient's home, there does not appear to be a contraindication to approving 24 hour homecare services for this patient.  As previously noted, the patient will need ADL assistance at various times throughout the day and night including incontinence care, and turning and positioning; 24 hour assistance is needed.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Assistance Services 24 hours per day, 7 days per week (live-in or Split-shifts), total of 168 hours per week is substantiated.  The insurer's denial is reversed.