Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied Personal Care Assistance, 24 hours per day, 7 days per week (Monday through Sunday) Split Shift. 
The denial is overturned in whole.

The patient is a female with a past medical history of anemia, constipation, hypertension, gastroesophageal reflux disease (GERD), depression, fatigue, osteoarthritis, chronic pain, diabetes, and urinary incontinence who had been assigned Personal Care Assistant (PCA) services 8 hours/day, 7 days/week to total 56 hours/week. The patient was hospitalized for her fall and hyponatremia. 
There was a request to increase PCA services to 24 hours/day, split shift, 7 days/week. The patient underwent uniform assessment and in the notes was stated that the patient was not able to get up out of bed or walk. The patient was transporting from bed to commode since she had been home from the hospital. Notes also stated the patient was bedbound. The patient was assessed at maximum assistance with tasks of meal preparation, ordinary housework, stairs, shopping, transportation, walking, locomotion, bathing, dressing lower body, transfer toilet, and bed mobility while extensive assistance was needed with tasks of managing finances, managing medication, equipment management, personal hygiene, dressing upper body, and toilet use. The patient was assessed at limited assistance with task of eating and independent with task of phone use. The PCA did all her personal care, dressing upper/lower body and her PCA did all meal prep, cleaning, laundry, assistance with finances, shopping, picking up medication, and reminders. The assessment also noted the patient's niece was not able to provide informal support and the patient had no other informal help.
At issue is the medical necessity of Personal Care Assistance, 24 hours per day, 7 days per week (Monday through Sunday) Split Shift.

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

The requested health service treatment of Personal Care Assistance, 24 hours per day, 7 days per week (Monday through Sunday) Split Shift is medically necessary for this patient.
The patient's primary care provider and home care provider have recommended 24-hour PCA care. There is documentation from the  assessment that the patient was bedbound since her recent hospitalization and that all personal care was done by the PCA. The assessment underestimated the patient's assistance needs as the documentation from the assessment nurse stated the PCA does all meal prep, cleaning, laundry, assist with finances, shopping, picking up medications, and reminders however the assistance level for these tasks were noted as maximum and extensive but should have been noted as total assistance. The patient requires assistance with ambulating and toileting which are unpredictable care needs that span a continuum of time. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. The patient does not have informal help during the day or in the overnight hours. 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, to total 168 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.