Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebral vascular accident
Treatment: Home health care
The insurer denied Personal Care Aide 7 Days x 12 Hours x 2 Shifts (Split Shift). 
The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease, cerebrovascular accident (CVA), urinary incontinence, bowel incontinence, hypertension, hyperlipidemia, and permanent pacemaker who had been assigned PCA (personal care aide) services based on the assessment the assessed the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, and locomotion while maximum assistance with tasks of managing finances, transportation, dressing lower body, and toilet use. With tasks of managing medication, equipment management, bathing, personal hygiene, dressing upper body, walking, transfer toilet, and bed mobility the patient was assessed at extensive assistance while set up only for phone use and independent with eating.

Personal Care Aide 7 Days x 12 Hours x 2 Shifts (Split Shift) are medically necessary for this patient. 
There is documentation of functional decline following the patient's cerebrovascular accident (CVA). The patient's Uniform Assessment System (UAS) showed significant increase in need for assistance with all activities of daily living (ADL). The plan's denial(s) reported no significant change in Instrumental activities of daily living (IADL) status but the patient did have significant change in her ADL assistance needs with an increase from extensive/maximum assistance to total assistance with most ADLs. In addition, the patient has 24-hour care needs. The patient requires total assistance with walking, locomotion, transfer toilet, toilet use, and maximum assistance with eating. The patient, therefore, 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 plan incorrectly assumed the daughter could provide informal care outside of all of the currently assigned PCA hours. The patient has had documented sacral ulcers and therefore would require turning and repositioning every 2 hours and daughter reports the patient has a diaper change and is repositioned every 2 hours overnight. The patient's care needs in the overnight hours would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide 7 Days x 12 Hours x 2 Shifts (Split Shift) 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.