Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied of Personal Care Services-24 hours a day, split shift(two 12-hour shifts), 7 days a week, for a total of 168 hours. 
The denial is overturned. 

The patient is a female with a past medical history of Alzheimer's dementia, diabetes mellitus type 2, carotid stenosis, osteoarthritis, constipation, anxiety, gastroesophageal reflux disease (GERD), urinary incontinence, and bowel incontinence who had been assigned 92 hours/week of personal care assistance (PCA) services with a mutual case with her husband. 
The insurer sent final adverse determination denial notice denying request to increase PCA services to 24 hours/day, split shift, 7 days/week. The patient and her family appealed denial decision. On the same date, the patient's medical provider appealed the denial decision. The patient's neurologist provided a letter requesting an increase in personal care services for the patient as medically necessary. The provider noted the patient required total assistance with activities of daily living (ADL)s and her care needs were at times simultaneous with her husband whom she shared PCA hours but also had divergent needs. In addition, the provider stated the patient's nighttime needs for assistance were frequent and often extended and medication to manage the patient's sleep disturbance had either been ineffective or was incompatible with other conditions for which she was treated.
At issue is the medical necessity of Personal Care Services-24 hours a day, split shift(two 12-hour shifts), 7 days a week, for a total of 168 hours.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Personal Care Services-24 hours a day, split shift(two 12-hour shifts), 7 days a week, for a total of 168 hours is medically necessary for this patient.
There is documentation from the patient's daughter and medical provider of worsening cognitive and physical decline. The patient had informal help from her husband prior to his significant change in health no longer allowing him to provide informal help. The patient's medical provider documented medical necessity of increased PCA services. The patient's family documented there is no physical space for an aide to sleep and the patient has assistance needs with walking, locomotion, transfer to the toilet, and toilet use with unscheduled and unpredictable 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 requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL)s. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 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 her own home.
Therefore, the requested health service/treatment of Personal Care Services-24 hours a day, split shift(two 12-hour shifts), 7 days a week, for a total of 168 hours is medically necessary.