Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident
Treatment: Personal care aide level 2- 12 hours per day, 7 days per week, for a total of 84 hours per week 
The insurer denied the personal care aide level 2- 12 hours per day, 7 days per week, for a total of 84 hours per week.
The determination is overturned.

The patient has a past medical history of hypertension, hyperlipidemia, hearing loss, bladder incontinence, bowel incontinence, dementia, chronic dizziness, gastroesophageal reflux disease (GERD), hemiplegia/hemiparesis with a history of a cerebrovascular accident (CVA), and coronary artery disease (CAD) who had been hospitalized with a hemorrhagic cerebrovascular accident (CVA) and was transferred to rehabilitation. The patient was discharged to home and had a telephonic assessment performed for personal care services assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, and shopping while maximum assistance with tasks of phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The patient was assigned personal care assistant (PCA) services 8.5 hours/day, 7 days/week to total 59.5 hours/week.

There was a request to increase the PCA services and the patient underwent an assessment tool over the telephone assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, bathing, dressing lower body, toilet use, and bed mobility while maximum assistance with tasks of phone use, personal hygiene, dressing upper body, and eating. It was noted on the assessment that "activity did not occur" for tasks of walking, locomotion, and transfer toilet. Notes from the assessment stated the patient was unable to express goals of care, lives alone, had decline in functional status, was bedbound, was wheeled by others in a wheelchair, and was incontinent of bowel and bladder.

The insurer sent an initial adverse determination denial notice denying the request to increase PCA hours to 12 hours/day, 7 days/week, to total 84 hours/week but partially approving an increase in PCA hours to 10.5 hours/day, 7 days/week, to total 73.5 hours/week. The denial stated the request for the increase in PCA hours was not medically necessary and a home health care agency was recommended for physical therapy (PT)/occupational therapy (OT) which the patient's niece refused. The insurer sent a final adverse determination denial notice reiterating denial of an increase in PCA services to 84 hours/week. The plan noted the requested increase in PCA hours did not meet criteria and some of the patient's abilities to perform daily activities stayed the same and some declined comparing the earier assessment to the later assessment. The patient's primary care physician (PCP) provided a letter requesting an urgent increase in home care hours for the patient due to rapidly deteriorating mental state and physical health. The letter further stated the patient is of advanced age, resides alone, and suffers chronic pain and severe age related physical debilities in which she is bed confined and requires human assistance in her movement and mobility. The letter also stated the patient wears diapers and requires multiple daytime and nighttime changes of soiled diapers and linens to prevent skin rash and irritation. She also has a history of falling and is high risk for falls. In addition, the PCP noted it was medically necessary for the patient to have two split shifts of 12 hours of home care daily and nightly, 7 days/week to maintain her current health and prevent her illnesses from progressing. At issue is the medical necessity of personal care aide level 2- 12 hours per day, 7 days per week, for a total of 84 hours per week.

The services are medically necessary. The patient has documented worsening physical and mental function following a hemorrhagic CVA which followed a prior CVA. The patient has severe osteoporosis with deformity and limited dexterity and function. The patient has dementia requiring assistance with activities of daily living (ADLs)/instrumental activities of daily living (IADLs). The patient was not able to complete or perform tasks of walking, locomotion or transfer to toilet assessment as she is bed bound. The patient requires at least maximum assistance with all ADLs/IADLs. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient requires PCA outside of the times there is informal help. The increase in PCA hours is not solely for safety and supervision, but to assist the patient with safe completion of ADLs/IADLs. The patient's ADL care needs cannot be met with adaptive equipment and medical supplies alone. 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 12 hours/day, 7 days/week, to total 84 hours/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 her own home.