Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence Issues
Treatment: personal care services, 24 hours a day live-in (13 hours per day), 7 days a week, a total of 91 hours a week
The insurer denied the personal care services, 24 hours a day live-in (13 hours per day), 7 days a week, a total of 91 hours a week.
The health plan's determination is overturned.

The patient is a female with a history of cerebrovascular accident (CVA), urinary incontinence, bowel incontinence, gastroesophageal reflux disease (GERD), hypothyroidism, hypertension, hyperlipidemia, constipation, and insomnia. She was assigned personal care assistant (PCA) services for 9 hours a day, 6 days a week, to total 54 hours a week. The patient was hospitalized with a CVA and subsequently was transferred to a rehabilitation facility. After 2 months the patient was discharged to home with private pay 24-hour aide services.

There was a request to increase PCA services and the patient underwent a telephonic assessment assessing the patient at total assistance with the tasks of ordinary housework, stairs, dressing upper and lower body, and toilet transfers while the patient required maximum assistance with tasks of meal preparation, managing medication, transportation, walking, locomotion, and toilet use. With the tasks of shopping, personal hygiene, and bed mobility the patient was assessed at extensive assistance while limited assistance was needed with the task of managing finances. The patient was assessed as set up with the task of managing finances and she was independent with task of eating. It was noted activity did not occur for task of bathing. Care logs were provided noting the patient's need for assistance with activities of daily living (ADL's) from 6:45 AM to 1:45 AM.

The patient's occupational therapist also provided a letter stating that the patient had been receiving services following the patient's brain hemorrhage resulting in a left-sided stroke with right-sided hemiparesis and hemiplegia. The note stated the patient was unable to functionally ambulate and required a wheelchair to navigate in her home. Due to overall muscle weakness and impaired balance and coordination the patient required physical assistance to and from her wheelchair as well as completing transfers with a quad cane. The letter also stated the patient required extensive activity for all ADL's and required total assistance with all instrumental activities of daily living (IADL's). In addition, the letter stated the patient resided alone and required 24 hours a day, 7 days a week care for safety and physical assistance due to being high risk for falls and requiring over 50 percent (%) of physical assistance for all self-care tasks. 

The requested health service and treatment of personal care services, 24 hours a day live-in (13 hours per day) 7 days a week to total 91 hours a week is medically necessary for the patient. There is documentation that the patient has hemiplegia from a stroke. The patient requires at least maximum assistance with the tasks of walking, locomotion, toilet transfers and toilet use. The patient therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs.
The plan assumed the patient had informal help outside of the currently assigned PCA services which was not the case. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours a day, live-in, 7 days a week, to total 91 hours a week are medically necessary for the 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 her own home.