Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, coronary artery disease and stroke
Treatment personal care assistance (PCA) 24 hours per day, 7 days per week (split shifts), for a total of 168 hours per week
The insurer denied coverage for personal care assistance 24 hours per day, 7 days per week (split shifts), for a total of 168 hours per week
The denial is overturned.

This is a patient with chronic medical problems including hypertension, coronary artery disease and recent stroke resulting in right hemiplegia. She is currently a patient at a skilled nursing facility (SNF) and was receiving subacute rehabilitation services. 

The Uniform Assessment System (UAS) report was reviewed. The assessment was performed at a SNF where the patient is currently residing. The patient's cognitive status is described a "minimally impaired." The patient requires extensive assistance for bathing, personal hygiene, upper body dressing and toilet transfers. Maximal assistance is required for lower body dressing, bed mobility and toilet use. She is totally dependent for locomotion and ambulation. The patient is frequently incontinent of bladder and continent of bowel. The UAS report compared to the assessment performed, documents a significant functional decline, including for bed mobility, locomotion and ambulation. The clinical records also document the patient having a stroke with resultant right hemiplegia, which is consistent with her functional decline.

The patient underwent subacute rehabilitation after the stroke and according to the therapy notes at the SNF, has made limited, if any functional improvement. Skilled therapy services have been discontinued. The clinical notes do not document any physician or complicated nursing care services that are required at this time. In addition, her treating physician, indicated the patient's care can be safely provided at home. He recommended a home health aide, "preferably 24/7 to provide the care needed for her safety and to meet her daily needs."
The patient's cognitive deficits and significant functional impairments; particularly after the recent stroke, support the medical necessity of the requested personal care assistance (PCA) 24 hours per day, 7 days per week (split shifts), for a total of 168 hours per week. Her condition and functional needs are at a level and unpredictable as to require the requested continuous care split shift; 24 hours, 7 days/week (split shifts). Based on the enclosed documents reviewed, this physician would agree with the patient's treating physician regarding the need for continuous home health aide care. The patient's health and safety can be appropriately provided and maintained by the requested personal care assistance (PCA) 24 hours per day, 7 days per week (split shifts), for a total of 168 hours per week.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).
From a physical medicine and rehabilitation perspective, personal care assistance (PCA) 24 hours per day, 7 days per week (split shifts), for a total of 168 hours per week is medically necessary.

The insurer's denial of coverage for personal care assistance 24 hours per day, 7 days per week (split shifts), for a total of 168 hours per week is overturned. Medical Necessity is substantiated.