Diagnosis: Back pain/injury.
Treatment: Personal Care Aide Services: 56 Hours per Week, Consumer Direct, 1 Client
The insurer denied Personal Care Aide Services: 56 Hours per Week, Consumer Direct, 1 Client.
The health plan's determination is overturned.

The patient is a male with past medical history of nicotine dependence, mitral regurgitation, anxiety, insomnia, urinary incontinence, low back pain, osteoarthritis, neck pain, neuropathy, migraines, and traumatic head injury who had been injured when a bathroom room collapsed on him. The patient had injury to shoulder, neck and head injury.

Personal Care Aide Services: 56 Hours per Week, Consumer Direct, 1 Client medically necessary for this patient.
There is documentation from the patient's medical provider multiple times of medical necessity of increased PCA (personal care aide) services initially recommended prior to him having neck surgery and subsequently following his surgery. The patient had assessment performed prior to surgery which would have underestimated his activities of daily living (ADL) and Instrumental activities of daily living (IADL) needs. Furthermore, the patient will need to have another surgery on his shoulder and will have continued increased ADL and IADL needs. The denial stated that the medical provider did not document why the patient's care needs cannot be completed and currently assigned hours however the medical provider documented medical necessity of increased PCA services and specifically outlined the assistance the patient needed. The patient did require limited assistance with toilet use which is an unpredictable and unscheduled care need that spans a continuum of time and the patient would need assistance outside of the time that he has informal support. The insured did not document a plan to meet these unpredictable and unscheduled care needs. 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.