Diagnosis: cerebrovascular accident
Treatment: Home health care
The insurer denied Personal Care Assistant (PCA) Hours: 7 Days per Week, 12 Hours per Day. The health plan's determination is overturned.

The patient is a male with past medical history of cerebrovascular accident (CVA) with right hemiparesis, vascular dementia, hypertension, hypertensive heart disease with heart failure, coronary artery disease, diabetes mellitus type 2, hyperlipidemia, diabetic polyneuropathy, depression, hypothyroidism, chronic kidney disease, kidney cancer, chronic obstructive pulmonary disease (COPD), chronic low back pain, lower extremity edema, bowel incontinence, bladder incontinence, and osteoarthritis who had been assigned PCA (personal care assistant) services.

Personal Care Assistant (PCA) Hours: 7 Days per Week, 12 Hours per Day are medically necessary for this patient.
There is documentation from the patient's PCP (primary care provider) of worsening cognitive and functional status. The PCP documented medical necessity for increased PCA services. There is documentation that the patient is bedbound and wheelchair-bound. The patient requires assistance with all activities except for bed mobility based on assessment tool. The patient has unpredictable and unscheduled 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 insurer failed to document a plan to provide activities of daily living (ADL) and Instrumental activities of daily living (IADL) assistance when the patient does not have informal help. The last assessment underestimated the patient's care needs and because the patient has 24-hour care needs a time-based tasking tool should not of been utilized. 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, PCA services 12 hours/day, 7 days/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.