Diagnosis: Stroke with dense left hemiplegia and aphasia

Treatment: Increase in Personal Care Aide (PCA) services to 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 increase in Personal Care Aide (PCA) services to Level 2: 12 hours per day - 7 days per week (Split-Shift) for a total of 168 hours per week.
The denial is overturned.

According to the medical records, the member is an adult female who is bed-bound from a severe stroke with dense left hemiplegia and aphasia. She also has heart failure, hyperlipidemia, hypertension, and osteoarthritis. She is incontinent of bowel and bladder and needs maximum assistance for bed mobility. She is at high risk for pressure ulcers and must be turned every two (2) hours for skin protection. Her incontinence is frequent, and because she is incontinent of urine and stool, mechanical measures for keeping her dry at night (such as a PureWick) are contraindicated. It has been documented that the member's incontinence requires change of pads roughly every 2 hours. Even if she were a candidate for a supra-pubic catheter, a high fiber diet to reduce bowel incontinence frequency and every 2 hour turns (by a caregiver) would still be medically necessary.

"Conclusions: Incontinent patients had higher Braden Scale scores and higher overall and FAPU prevalence. Incontinence was associated with an increased risk for all pressure ulcers, but especially full-thickness injuries." (Lachenbruch, C. et al.).

"The prevention and treatment of pressure ulcers are highly relevant to wound care professionals. These patients require prolonged course of treatment to fully heal their wounds. The biomedical burden is tremendous as noted above and healthcare expenditures on this problem are only rising. Penalties now imposed for hospital-acquired pressure ulcers mean we need greater knowledge about causation and prevention." (Boyko, T. V. et al.).

Landers, S., et al., "Medicare skilled home health" care or "home health care" refers to services offered by Medicare-certified home health agencies under the Medicare home health benefit. By contrast, "home-based care" refers to a wide array of different types of care provided in the home by a wide range of parties. The continuum of different types of home-based care delivered in the home varies in terms of different dimensions, including acuity, type of care provided, and degree of physician involvement. Home-based care includes both formal and informal personal care services, Medicare skilled home health, physician house calls, and even "hospital-at-home" services."

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an increase in Personal Care Aide (PCA) services to Level 2: 12 hours per day - 7 days per week (Split-Shift) for a total of 168 hours per week is substantiated.