Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident with residual right sided hemiparesis

Treatment: Increase Personal Care Aide Level II PCS To Seven (7) Days per Week, Twenty-four (24) Hours per Day (Split Shift)

The insurer denied the Increase Personal Care Aide Level II PCS To Seven (7) Days per Week, Twenty-four (24) Hours per Day (Split Shift).

The denial is overturned. 

This male patient has conditions including recent cerebral vascular accident (CVA) with residual right-sided hemiparesis.  The patient lives alone.  This is an appeal of denial for increase Personal Care Aide Level II personal care services (PCS) from 84 hours per week to seven days per week, 24 hours a day, split shift.  

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, transportation, bathing, lower body dressing, locomotion, and toileting; maximal assistance with managing finances and medications, shopping, personal hygiene, upper body dressing, and bed mobility; and extensive assistance with phone use and eating.  Uses wheelchair, wheeled by others.  Has bowel and bladder incontinence.  He is status post (S/P) two falls in last 90 days.  

Appeal statement from the health plan notes the patient needs assistance with activities of daily living (ADLs).  It states the patient is unable to walk and use wheelchair without assistance.  The patient needs to be turned every two hours.  He has had two falls in the last few months.  A letter from the provider states the patient is bedbound and completely dependent.  It recommend care 24 hours for seven days per week.

Yes, the proposed increase in personal assistance services is medically necessary.

Personal assistance services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the provider five hours daily of uninterrupted sleep during the aide's shift.

This patient has multiple chronic conditions including a recent stroke with residual hemiparesis.  This is an appeal of denial for increase of Personal Care Aide Level II PCS from 84 hours per week to seven days per week, 24 hours a day, split shift.  Uniform Assessment System (UAS) evaluation performed shows the patient requires assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs).  He requires assistance in wheelchair for locomotion.  Appeal letter from the provider notes the patient is bedbound and completely dependent.  The patient requires maximal assistance with bed mobility and requires turning/repositioning every two hours.  This patient has continuous needs that cannot be met with the approved personal care aide (PCA) 84 hours per week.  The need for frequent repositioning/turning in bed is unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.  The proposed increase in personal care aide (PCA) to a 24 hours per day, split shift, is medically necessary to meets this patient's need for assistance with activities of daily living (ADLs) and personal care.