Diagnosis: cerebral vascular accident (CVA).
Treatment: Personal Care Services (PCS) - Total of 168 Hours per Week.
The insurer denied the Personal Care Services (PCS) - Total of 168 Hours per Week.
The denial is upheld.

This female patient has diagnoses including status post cerebral vascular accident (CVA), quadriplegia, tracheostomy, chronic respiratory failure, and gastrostomy tube. She lives in a one bedroom apartment. She is appealing the denial of decrease in personal care services (PCS) to a total of 168 hours per week. The health plan is reducing hours to 51 hours per week. The patient has 168 hours of private duty nursing. The patient has a hospital bed and a Hoyer lift for transfers.

An appeal letter notes the patient needs trach care with inner cannula change twice daily, suctioning, oxygen level monitoring, nebulizers four times per day, medication administration via percutaneous endoscopic gastrostomy (PEG) tube, heparin injections, ophthalmic drops, percutaneous endoscopic gastrostomy (PEG) tube feeds and flushes, seizure monitoring, and turn and reposition every two to three hours. The patient requires total assistance with all activities of daily living (ADLs). Twenty-four hours split shift licensed practical nurse (LPN) and personal care services (PCS) care is needed due to high care and unscheduled needs.

No, the proposed treatment, Personal Care Services (PCS) - Total of 168 Hours per Week, is not medically necessary.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has quadriplegia, a tracheostomy for chronic respiratory failure, and gastrostomy tube. The patient has 160 hours of private duty nursing. She is appealing denial of decrease in PCS a total of 168 hours per week. The health plan is reducing hours to 51 hours per week. The patient requires care with tracheostomy, suctioning, medications, feeding, and frequent repositioning. An appeal statements states 24-hour personal care services (PCS) are required to assist the licensed practical nurse (LPN) due to the patient's needs. Personal care services (PCS) are indicated to provide assistance with transferring, bathing, dressing, and housework. Personal care services are not indicated to provide medical care. The approved personal care services 51 hours per week is appropriate and medically necessary to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care. The proposed personal care services (PCS) of 168 hours per week is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.