Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident (CVA)
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week: 12 hours per day - 7 day(s) per week - a total of 168 hours per week
The insurer denied Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week: 12 hours per day - 7 day(s) per week - a total of 168 hours per week.
The determination is overturned.

This is a female patient with a past medical history of hypertension, thyroid disease, spinal stenosis, degenerative joint disease (DJD), depression, osteoporosis, urinary incontinence, and memory disorder who had personal care assistant (PCA) services based on an assessment assessing the patient at total assistance with the tasks of ordinary housework and shopping while maximum assistance with the tasks of meal preparation, stairs, transportation, bathing, and dressing lower body. With the tasks of managing finances, managing medication, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility the patient was assessed at extensive assistance while set up with the task of phone use and independent with the task of eating.
The patient had a fall and cerebrovascular accident (CVA) with admission to the hospital with subsequent transfer to rehabilitation. There was a request to increase PCA services and the patient underwent another assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, and transportation while maximum assistance with the tasks of phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient was assessed at limited assistance with the task of eating.
The insurer sent a final adverse determination denial notice continuing to deny the request to increase PCA services and approving 59.5 hours/week. The denial stated granting additional hours could not be provided when tasks were not being performed and for safety monitoring and supervision and there was no additional clinical documentation received with the appeal for review.
A caregiver log  during the day noted assistance with activities of daily living (ADLs) at least every hour. A night shift care log noted assistance needs with ADLs, specifically repositioning in bed, assisting with medication administration, and toileting, at least every 2-1/2 hours.  
At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week: 12 hours per day - 7 day(s) per week -a total of 168 hours per week.
The services are medically necessary.
The patient had a CVA with documentation of left hemiparesis and worsening cognitive and physical functioning. The patient's medical provider documented medical necessity of increased PCA services to 12 hours/day x 2, split shift, 7 days/week. The plan's assessment documented that the patient required maximum assistance with the tasks of walking, locomotion, transfer toilet, and toilet use and therefore had unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. Overnight care logs document the patient's care needs at least every 2 and a half hours which would not allow a PCA 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies.