Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Stroke/CVA (Cerebrovascular accident).
Treatment: Home Health Care- Personal Care Aid (PCA).
The health plan denied an increase in Personal Care Aid hours as not medically necessary. The reviewer has overturned in whole the health plan's determination.

This is a case review for a female patient with medical history notable for prior cerebral infarction resulting in right sided hemiplegia/hemiparesis, heart disease, urinary incontinence, and arthritis. The patient is approved for 7.5 hours per day, 7 days per week (52.5 hours per week) of level 2 personal care services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.
The patient's primary care physician provided a letter of support for this appeal. The letter states that the patient's medical conditions have resulted in impairment of her ability to perform daily activities. She needs hands-on assistance with ambulation, toileting, and transfers. The physician states that she requires assistance during all waking hours, and therefore supports the requested increase as medically necessary.
The patient's daughter provided a letter of support for this appeal. The letter states that the patient lives alone, and her daughter lives in a different state and can only provide limited informal support. She is not able to help support her mother's daily activities. She notes that her mother requires assistance with walking, meal preparation, and attending appointments, among other tasks. A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted in-person. The patient lives alone in her apartment. The patient was alert and oriented to person and place only; she has difficulty expressing herself due to global aphasia. Cognition is noted to have declined. For her instrumental activities of daily living (IADL's), she requires total dependence for meal preparation, housework, finances, stairs, and shopping. She requires maximal assistance for managing medications and phone use. For her activities of daily living (ADL's), she requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She is frequently incontinent of urine and uses pullups for incontinence care. Compared to a prior UAS she showed a functional and cognitive decline. A task tool associated with the assessment recommended 52.5 hours per week to address her personal care needs.

The requested health service of personal care aide (PCA): 12 hours per day- 7 days per week- for a total of 84 hours per week is medically necessary for this patient.
The patient requires hands-on assistance for all of her ADL's and IADL's. She is not able to ambulate, transfer, or toilet without assistance. She has urinary incontinence and cannot independently manage her incontinence care. Her personal care needs can be expected to be continuous and unscheduled throughout the day and cannot be scheduled into a 7.5 hour block each day. The requested increase in personal care hours is medically reasonable and appropriate for a person who requires this level of assistance with personal care.