Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Other/Gait Ataxia. 
Treatment: Home Health Care/Personal Care Aide (PCA) Services: 8 Hours per Day, 5 Days per Week - Total Amount of 40 Hours per Week. 

The health plan denied the requested Personal Care Aide (PCA) Services: 8 Hours per Day, 5 Days per Week - Total Amount of 40 Hours per Week as not medically necessary. 

The health plan's determination is overturned. 

The patient is a male with a past medical history of vascular dementia, cerebrovascular accident (CVA), hyperlipidemia, low back pain, hypertension, diabetes mellitus type 2, bladder cancer, seizure disorder, urinary incontinence, bowel incontinence, cannabis abuse, cataracts, and peptic ulcer disease who had personal care aide (PCA) services 4 hours/day, 5 days/week, to total 20 hours/week, based on a telephonic assessment. This assessed the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, shopping, and transportation while extensive assistance with tasks of managing medication, stairs, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at supervision with the task of phone use while independent with tasks of bed mobility and eating. The tasking tool estimated 27.5 hours/week. The patient had been admitted to the hospital with a seizure disorder. He was subsequently diagnosed with metastatic cancer to the lumbar spine. 

The patient's neurologist provided a letter stating the patient had vascular dementia following a stroke a few years ago and had memory loss and gait ataxia with trouble with activities of daily living (ADLs), including cooking, cleaning, bathing, and putting on clothing. The provider stated that due to worsening of the patient's symptoms, the patient would need an increase in his home health aide hours. The provider specifically recommended help with aide services 12 hours a day, 7 days a week. The patient had an emergency room visit due to chest pain and was diagnosed with gastroesophageal reflux disease (GERD). 

At issue is the medical necessity for the requested health service/treatment of Personal Care Aide (PCA) Services: 8 Hours per day, 5 days per week - total amount of 40 hours per week. 

The health plan's determination of medical necessity is overturned, in whole. 

There is documentation from the patient's medical provider for the medical necessity of increased PCA services due to worsening symptoms vascular dementia. The tasking tool estimated assistance needs 35 hours/week, yet the plan continued to only improve 20 hours/week. The patient requires maximum assistance with walking, locomotion, and transfer toilet and therefore, has unpredictable and unscheduled care needs that span a continuum of time. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). 

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 8 hours per day, 5 days per week - total amount of 40 hours per week are medically necessary for this 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 his own home.