Diagnosis: Multiple Sclerosis
Treatment: Personal Care Aide (PCA) Level 2 Services: 9 Hours per Day, 7 Hours per Week - Total of 63 Hours per Week.
The insurer denied Personal Care Aide (PCA) Level 2 Services: 9 Hours per Day, 7 Hours per Week - Total of 63 Hours per Week.
The health plan's determination is overturned.

The patient is a female with past medical history of multiple sclerosis and urinary incontinence who had been assigned PCA (personal care aide) services based on an assessment performed via telephone assessing the patient at maximum assistance with tasks of preparation, ordinary housework, managing medication, managing finances, and shopping while extensive assistance with tasks of transportation, bathing, and dressing lower body. With tasks of stairs, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at limited assistance while set up only with task of phone use. The patient was assessed at independent with tasks of bed mobility eating. There was a request to increase PCA services.

Personal Care Aide (PCA) Level 2 Services: 9 Hours per Day, 7 Hours per Week - Total of 63 Hours per Week are medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased PCA services. The patient requires assistance with all activities of daily living (ADL) except for toilet use, bed mobility, and eating. The patient therefore has unpredictable and unscheduled care needs that span a continual time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The plan suggested splitting hours to better meet morning and evening needs but they have been unable to find an aide to work the short shifts. The patient requires prompting to complete some Instrumental activities of daily living (IADL) and ADLs due to worsening cognitive function. 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. 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 level 2 services 9 hours/day, 7 days/week, to total 63 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 her own home.