Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/ Neuromuscular Disorder
Home Health Care

Diagnosis: Other- hemiplegia 
Treatment: Personal Care Aide (PCA) Level 2 Services: 12 hours per day - 7 days a week (split-shift) - total of 168 hours per week

The health plan denied:Personal Care Aide (PCA) Level 2 Services: 12 hours per day - 7 days a week (split-shift) - total of 168 hours per week 
The determination is: Overturned

The patient is a female with a medical history notable for hemiplegia and hemiparesis following a cerebral infarction with impaired mobility. The patient is currently residing in a skilled nursing facility. The patient and her care team requested 24-hour split-shift personal care services, 7 days per week (168 hours per week) as part of her discharge plan. The plan approved the patient for 8.5 hours per day, 7 days per week (59.5 hours per week).

The patient's internal medicine physician provided a letter of support for this appeal. The letter states that the patient requires assistance for transfers, toileting, and bed mobility. She is incontinent of both urine and stool. She requires nighttime changes of diapers to prevent infection and skin breakdown. She has a history of multiple urinary traction infections, and she has a history of pressure ulcers. Therefore, the physician attests that the patient requires 24 hour split-shift care as medically necessary to meet her personal care needs.

The patient's spouse provided a letter for this appeal. The letter states that he had recent heart surgery to repair multiple valves. He has multiple medical problems of his own. He is no longer able to assist his wife with any personal care tasks.

A Uniform Assessment System (UAS) was available for review. The patient was alert and oriented to person and place only; she had impaired short term and procedural memory. She requires supervision at all times. For her instrumental activities of daily living (IADL's), she requires maximal assistance or total dependence for all. For her activities of daily living, she requires total dependence for walking and locomotion. She requires limited assistance for eating. She requires maximal assistance for all other tasks including toileting and bed mobility. She is frequently incontinent of urine and occasionally incontinent of stool. Compared to a prior assessment, she showed a decline in functional status.

In an occupational therapy assessment completed at the nursing facility, the patient was noted to have developed pressure ulcers. These included a stage 3 ulcer on both the left and right buttock, as well as a stage 3 pressure ulcer of the right heel and stage 2 ulcer of the left heel. The patient requires repositioning every 2 hours to address these ulcers.
At issue is the medical necessity of Personal Care Aide (PCA) Level 2 Services: 12 hours per day - 7 days a week (split-shift) - total of 168 hours per week.

The health plan's determination of medical necessity is overturned in whole.
The requested health service of Personal Care Aide (PCA) Level 2 Services: 12 hours per day - 7 days a week (split-shift) - total of 168 hours per week is medically necessary for this patient.
The patient requires hands-on assistance for all activities of daily living due to her cognitive and functional impairments, which are sequelae of a stroke. She cannot complete any tasks without human assistance, including transfers, ambulation, toileting, and bed mobility. She developed numerous pressure ulcers despite being in a skilled nursing care setting. She will require turning and repositioning every 2 hours throughout the day and night to promote healing and prevent development of new wounds. She will require prompt incontinence care and toileting to prevent infections and development of new wounds. Her personal care needs are continuous throughout the day and night. Therefore, the requested increase to 24 hour split-shift personal care is medically necessary and reasonable for the patient.