Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular Accident (CVA) and Osteoarthritis	

Treatment personal care aide (PCA) level 2 services, 12 hours per day, 7 days per week (total of 84 hours per week)

The insurer denied coverage for personal care aide (PCA) level 2 services, 12 hours per day, 7 days per week (total of 84 hours per week)

The denial is overturned

This patient has an extensive medical history associated with substantial functional impairment. The patient lives alone.  She needs assistance with all daily activities which she receives primarily from personal care aide (PCA) services 7 hours per day, 7 days per week (schedule noted as 7am (anti meridiem)-2pm (post meridiem)). The patient's son is the only informal caregiver identified in the Uniform Assessment System (UAS). He provides some assistance when the PCA is not present. Request was made for increase of PCA services to 12 hours per day, 7 days per week, which was denied. An external appeal was requested.

The patient has frequent bladder and bowel incontinence. It was noted that the frequency of incontinence increased since the stroke. It is not known from the available records whether incontinence became worse due to neurologic sequelae from the stroke; but it is likely that the patient's decline in mobility causes delay in reaching the toilet or commode, which can result in functional incontinence (inability to reach a toilet in time). The frequency of using the toilet or commode is not clear. The UAS indicates the patient no longer walks and needs maximal assistance for transfer to the toilet. It was not reported how often the patient uses the toilet or commode when the aide is present. However, considering the patient's need for substantial assistance for transfers and toilet use, it does not seem possible for the patient to use even a bedside commode when there is no caregiver present. 

Considering the patient's medical history and functional status as noted in the available records, it is apparent that the patient needs substantial assistance for all instrumental activities of daily living (IADLs) and activities of daily living (ADLs). Therefore, it is medically necessary, and in the patient's best interest, to have a caregiver present throughout the day to provide assistance for daily activities. The patient needs assistance for IADLs and ADLs that occur at various scheduled and unscheduled times throughout the day. This includes routine household tasks, and preparation/service of all 3 meals; assistance with eating all meals; routine morning and evening ADLs (e.g., bathing, dressing, personal hygiene); and unscheduled/recurring activities, including toileting related tasks/incontinence care; out-of-bed mobility (transfers, wheelchair mobility); repositioning in bed and wheelchair. Without adequate assistance, the patient is at high risk for adverse health and safety events, e.g., skin damage due to incontinence and pressure; nutritional decline, hypoglycemia (if patient misses meals when alone); falls/injury. MLTC (Managed Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all the patient's care needs throughout the day must be considered in the determination of the patient's personal care service hours.

The patient will benefit from increase of PCA services to 12 hours per day. Personal Care Aide services Level 2: 12 hours per day, 7 days per week; total of 84 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment.

The insurer's denial of coverage for personal care aide (PCA) level 2 services, 12 hours per day, 7 days per week (total of 84 hours per week) is overturned. Medical necessity is substantiated.