Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Stroke/CVA
Treatment: Home Health Care-Personal Care Services Increase
The plan denied the increase in Personal Care Services per 15 minutes at 91 hours per week as not medically necessary for this patient. 
The reviewer has overturned in whole the health plan's determination. 

The patient has a past medical history of cerebrovascular accident (CVA), dementia, hypertension and is wheelchair-bound status who had been assigned 91 hours of personal care aid (PCA) services. Medical records document the patient had a CVA, has severe dementia and was wheelchair-bound. There was a review to continue PCA services and the PCA hours were changed to 57 hours/week as noted in an initial adverse determination denial notice. The patient's primary care physician (or provider) (PCP) provided a letter documenting the medical necessity of increased home care assistance. The request from the provider was for at least 14 hours per day. The provider noted the patient was unable to move his legs, ambulate, or stand on his own. In addition, the provider noted the patient is unable to lift a cup to his mouth. The letter also stated the patient was at high risk for stasis ulcers due to immobility and the patient was unable to reposition himself, feed himself, or remain safe throughout the day. Lastly, the provider noted the patient's family does care for him, but they work long hours and are unable to monitor patient and the patient has dementia which is a chronic and progressive disease. The final adverse determination notice continued to approve/reduced PCA services to 57 hours/week. The denial stated the patient did not meet the criteria to fully approve the request as the Uniform Assessment System (UAS) evaluation/nurse assessment should show that the patient needed 91 hours of assistance and the criteria was not met because per the nursing assessment done, the patient's care needs could be met in 57 hours/week. The UAS assessment was not available for review with the documents submitted.

The increase in Personal Care Services is medically necessary for this patient.
The patient's PCP provided documentation of medical necessity for increased PCA services. The patient is bedbound, uses a Hoyer lift, and is unable to feed himself, turn and reposition himself or perform activities of daily living (ADLs) / instrumental activities of daily living (IADLs) without assistance. The patient has unpredictable and unscheduled care needs that span a continuum of time. The patient requires turning and repositioning to prevent skin breakdown and infection. The family could not provide informal care outside of the hours of PCA services,  according to the PCP. Considering clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Consumer Directed Personal Assistance Program (CDPAP) /PCA services 91 hours/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 his own home.