Diagnosis: cerebral vascular accident
Treatment: home health care
The insurer denied Personal Care Services (PCS): 12 Hours per Day, 7 Days per Week (Total of 84 Hours).
The health plan's determination is overturned.

The patient is a female with medical history notable for incontinence, wheelchair bound status, prior stroke, and pain. The patient's primary care physician provided a letter of support for this appeal. The letter states that the patient has diabetes, hypertension, chronic obstructive pulmonary disease (COPD) on home oxygen, and a prior cerebrovascular accident (CVA) with resulting right sided weakness and difficulty ambulating. She requires assistance with all activities of daily living including toileting, bathing, and dressing.

The requested health service of Personal Care Services (PCS): 12 Hours per Day, 7 Days per Week (Total of 84 Hours) is medically necessary for this patient.
The patient requires hands-on assistance for all activities of daily living. She is wheelchair bound. She has incontinence of urine and stool. She is not able to toilet or manage her own incontinence care independently. She will require personal care assistance throughout the day. A task tool cannot be relied on to accurately reflect her true need, given that her care needs are expected to be continuous and unscheduled throughout the day. Therefore, the requested services are medically necessary for this patient.