Diagnosis: CVA.
Treatment: Home health care.

The insurer denied Personal Care Assistance Services: 56 Hours per Week.
The health plan's determination is overturned.

The patient is a male with past medical history of hypertension, cerebrovascular accident (CVA), benign prostatic hyperplasia (BPH), coronary artery disease, hearing loss, permanent pacemaker, osteoarthritis, hyperlipidemia, and urinary incontinence who had been assigned PCA (personal care assistance) services based on telephonic assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while extensive assistance with tasks of managing medication, phone use, stairs, transportation, equipment management, bathing, dressing lower body, and toilet use. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, and transfer toilet while independent with tasks of bed mobility and eating.

Personal Care Assistance Services: 56 hours per week are medically necessary for this patient.

The patient was recently hospitalized with subsequent rehabilitation stay and the patient's assessment documents an increased need in assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, stairs, shopping, transportation, equipment management, bathing, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, bed mobility, and eating. It was assumed that the patient has informal help outside of the currently approved PCA services. The patient 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 requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). 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, PCA services 56 hours/week 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 his own home.