Diagnosis: Central nervous system/neuromuscular disorder/other.
Treatment: Home health care.

The insurer denied Personal care assistance services hours 7 hours per day, 7 days per week for a total of 49 hours per week. The denial is overturned in whole.

The patient is a male with a past medical history of hypertension, diabetes mellitus (DM) type 2, human immunodeficiency virus (HIV), cerebrovascular accident (CVA) with right sided weakness, bladder incontinence, coronary artery disease, gout and chronic pain. The patient had been assigned Personal Care Assistant (PCA) service hours 5 hours/day, 3 days/week and 3 hours/day, 2 days/week to total 21 hours/week. Yes, the Personal care assistance service hours to 7 hours per day, 7 days a week for total of 49 hours per week is medically necessary.

The patient was documented to have chronic dizziness and increased risk of falls with a hospitalization related to a fall. The plan denied increase in PCA hours stating the increase was for safety and supervision only.

The patient requires assistance with unscheduled needs, and that assistance is to safely perform Activities of daily living (ADL's). The PCA service hour increase is not solely for supervision and safety. The patient has increased assistance needs with tasks of transfer toilet, toilet use and personal hygiene as he does wear incontinence pads and has right sided weakness from previous stroke. The goal of PCA services is to allow the patient to maintain independence in his community environment, and the increase in PCA hours for this patient would help the patient to reach this goal.