Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Central Nervous System/Neuromuscular Disorder - Cerebrovascular Accident. 
Treatment: Home Health Care. 

The insurer denied personal care aide (PCA) level 2: 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week. 
The denial is partially overturned. 

The patient is a female with past medical history of hypertension, coronary artery disease, cerebrovascular accident (CVA), dementia, asthma, osteoporosis, gastroesophageal reflux disease (GERD), heart block, osteoporosis, pacemaker, prediabetes, osteoarthritis, urinary incontinence, bowel incontinence, and depression who had been assigned Personal Care Assistance (PCA) services 7 hours/day, 7 days/week, to total 49 hours/week based on assessment performed assessing the patient at total assistance with ordinary housework and stairs while maximum assistance with tasks of meal preparation, managing finances, managing medication, shopping, equipment management, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. With task of bed mobility the patient was assessed at extensive assistance while set up only with task of bed mobility. The patient was assessed at independent with task of eating. 

The health plan's determination is partially overturned. 

No, PCA services 12 hours/day, split shift, 7 days/week, to total 168 hours/week are not medically necessary but PCA services 24 hours/day, live-in, 7 days/week are medically necessary. 

There is documentation of worsening functional status, specifically with the patient's ability to perform any tasks utilizing her hands, ambulation, and difficulty with communication. The patient has care needs outside of the currently assigned PCA services and the insurer failed to document a plan for these care needs. The patient's family is unable to provide informal support at a level they were previously able to provide. The request was for 2 split shift 12-hours per day, 7 days/week, to total 168 hours/week however the patient did not have documentation of overnight care needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The patient has 24-hour care needs and therefore a task based assessment should not have been utilized on this patient. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, live-in, 7 days/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.