Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Home Health Care
Diagnosis:  CVA
Treatment: Consumer directed personal care assistance 8 hours per day, 7 days per week - 56 hours per week 
The insurer denied consumer directed personal care assistance 8 hours per day, 7 days per week - 56 hours per week 
The determination is overturned.

The patient has a past medical history of hypertension, coronary artery disease, atrial fibrillation on chronic anticoagulation, diabetes mellitus type 2 with insulin therapy, prior cerebrovascular accident (CVA) and hospitalization for acute left pontine CVA with resultant dysarthria and right sided weakness. Prior to hospitalization, the patient had Consumer-Directed Personal Assistance Services (CDPAS) 34 hours per week. The patient was admitted to acute rehabilitation with documentation of a soft diet with thin liquids and weakness at 4/5 on the right side. Physical therapy documented that the patient required increased assistance with ambulation and needed to use a quad cane with a forearm crutch and not able to use the recommended wheeled walker due to limited space in his home. The patient was able to walk 130 feet with a rollator walker and assistance and able to walk 40 feet with minimum assistance using the quad cane and forearm crutch.
The patient was treated with basal insulin once daily and sliding scale insulin before meals and at bedtime. His provider requested an increase in CDPAS hours to 8 hours/day, 7 days/week to total 56 hours/week. The patient had an assessment tool performed while at acute rehabilitation. It is documented that the patient is not able to walk independently and requires one person and a cane, as well as one person to stand up from a wheelchair, sit up or stand up in bed, sit and stand up on the toilet. The assessment documented the patient was able to walk 130 feet and required reminders to take medication. The patient lives with his two sons who each work five days per week. At the time of the assessment tool , the patient was assessed as needing total assistance with meal preparation, ordinary housework, transportation while maximal assistance with tasks of managing finance, transportation and dressing lower extremities. In addition, the patient was assessed as needing extensive assistance with managing medication, stairs, bathing, personal hygiene, dressing upper extremities, walking, transfer toilet and toilet use while assessed at limited assistance with bed mobility. The patient was assessed as independent with eating. At issue is the medical necessity of consumer directed personal care assistance 8 hours per day, 7 days per week - 56 hours.
The requested consumer directed personal care assistance 8 hours per day, 7 days per week, a total of 56 hours per week is medically necessary for this patient. The patient had a new CVA with resultant dysarthria and right sided weakness making his needs for activities of daily living (ADLs)increased from prior to the CVA. The assessment tool does not take into consideration the patient's need for insulin injections. The patient was noted to require the use of a quad cane and forearm crutch to ambulate as he could not use a rollator walker in his home. He was only able to ambulate 30-40 ft with the use of quad cane and forearm crutch as opposed to the 130 feet documented a day later in the assessment tool. The patient requires assistance and supervision to ambulate safely for unscheduled task of toileting. The patient is treated with an oral anticoagulant increasing the risk of injury with any resultant falls from unsafe locomotion or walking. Because of the newly diagnosed CVA, the patient has increased needs for supervision to safely complete his ADLs which is not taken into account on the assessment tool. The CDPAS increase is medically necessary for this patient to prevent illness or infirmity and/or allow the patient to return to normal activity that is allowable given his disabilities from the recent CVA.