Diagnosis: Hypertension, hypothyroid, dementia, history of 2 strokes

Treatment Personal Care Aide (PCA) Level 2: 12 hours per day 7 days per week (split shift)- for a total of 168 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day 7 days per week (split shift)- for a total of 168 hours per week

The denial is overturned

The patient is a woman with multiple medical problems including hypertension, hypothyroid and dementia. She also has a history of 2 strokes. The insurer approved Personal Care Aide (PCA) of 11 hours/week, 7 days/week for a total of 77 hours/week. Under review is the request for PCA Level 2: 12 hours/day-7days/week (split shift)- for a total of 168 hours/week.

According to the Uniform Assessment System (UAS) report , the patient has significant cognitive deficits. Cognitive skills are described as "severely impaired." She is oriented only to person and does not recognize caregivers or family members. The patient is totally dependent for activities of daily living tasks that include personal hygiene, dressing and toilet use. She is incontinent of bowel and bladder. The patient is also totally dependent for bed mobility and is non-ambulatory. She is bed bound, unable to feed or reposition herself. The patient's severe dementia and progressive functional declined after a nearly 2-month hospitalization due to another stroke, this supports the medical necessity of personal care assistance (PCA) 24hours per day, 7 days per week split shift, to allow her to resume living safely at home.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).

The requested increase Personal Care Aide (PCA) Level 2: 12 hours per day-7days per week (split shift)- for a total of 168 hours per week is medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Personal Care Aide (PCA) Level 2: 12 hours per day-7days per week (split shift)- for a total of 168 hours per week is overturned. Medical Necessity is substantiated.