Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute/Subacute Cerebrovascular Accident
 
Treatment: Personal Care Aide (PCA) Level 2 services

The insurer denied the Personal Care Aide (PCA) Level 2 services.
The denial was reversed. 

This patient is an elderly female who was brought to emergency department with report of facial droop and low systolic blood pressure. The patient had a history of cerebral vascular accident (CVA) in early 2019 with residual deficits. On this admission, Computerized Tomography (CT) scan head showed new acute ischemic changes in right pons. She has an extensive medical history and substantial functional impairments. The patient was hospitalized twice in the past 2-3 months for CVA which resulted in further functional decline to the point where she is totally dependent on caregiver assistance for all daily activities (IADLs and ADLs).
Patient was discharged home to her apartment where she lives alone with home visit program; prognosis: poor

In mid-2019 Physician home visit for evaluation of sacral ulcer: stage IV sacral ulcer, 3cm x 1 cm x 0.5 cm; base is clean; no discharge. Patient is incontinent of urine. Plan: clean with normal saline (NS), cover with dry gauze; turn every 2 hours; diapers should be changed promptly when wet; high protein, high calorie diet; patient needs 24 hour aide as she needs to be turned every 2 hours to promote wound healing. Approximately 1 month later Physician home visit Diagnoses: CVA, hypertension (HTN), congestive heart failure (CHF), decubitus. Patient has left hemiparesis with very poor strength lower extremities. Patient is bedbound. She has difficulty swallowing liquids, aspiration precautions noted. The patient needs assistance for all ADLs. She is non-ambulatory. 

There is no apparent need for the patient to get out of bed at night. However, there are several aspects of the patient's care that need to be managed throughout the night. The patient has a sacral pressure ulcer identified a stage IV pressure ulcer without necrosis or signs of infection in mid- 2019. The patient has urinary and fecal incontinence. When pressure ulcers are present on the sacral, buttocks area, it is necessary to keep the ulcers clean and dry. Wound dressings often become soiled and are displaced following episodes of incontinence, exposing the wound to moisture and contamination. Prompt attention to incontinence episodes is a necessary part of wound care and preventive skin care; as chronic moisture from incontinence can adversely affect wound healing, and can increase the risk of pressure ulcers and incontinence associated dermatitis.
The physician who evaluated the patient in mid-2019 recommended turning the patient every 2 hours. This is an accepted timeframe for turning patients to reduce pressure. For some high risk situations, the turning schedule may need to be more frequent. With a 24 hour live-in aide, the patient would not be repositioned for 5 hours each night, which is not an acceptable time frame for this patient, considering her severe mobility impairment, the presence of a sacral pressure ulcer and high risk for future skin injury. 

The carrier's denial of coverage for Personal Care Aide (PCA) Level 2 services: 12 hours per day/7 days per week; 12 hours per day/7 days per week - total of 168 hours (split-shift) is reversed.  The medical necessity is substantiated.