Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System /Neuromuscular Disorder.
Treatment: Home Health Care.
The insurer denied: 24 hrs/day/7 days wk. split shift personal care services.
The denial is: Overturned in whole. 

The patient is a  female with past medical history of limb girdle muscular dystrophy (wheel chair dependent), quadriplegia, urinary incontinence, history of falls, insomnia, iron deficiency anemia, restrictive lung disease, fracture of right femur and vitamin D deficiency who had been assigned 108 hours/week of Personal Care Assistance (PCA) services. PCA service hours were 12 hours/day, 5 days a week and 24 hours/day, 2 days a week. The patient worked full time and did not have PCA service hours for 12 hours during the day Monday through Friday.

The patient has a right femur fracture following a mechanical fall with subsequent rehabilitation stay. The patient had an assessment tool and was noted to be independent with managing finances, phone use and locomotion, required limited assistance with eating, required extensive assistance with tasks of managing medication and personal hygiene, required maximal assistance with tasks of meal preparation, shopping, transportation, bathing, dressing upper body, transfer toilet, toilet use and bed mobility, while requiring total assistance with tasks of ordinary housework, stairs and dressing lower body. The patient was unemployed due to complications from previous femur fracture and there was request for an increase in PCA service hours to 24 hours/day, split-shift, 7 days/week to total 168 hours/week. A letter from the patient on stated she is experiencing pain from being stuck in one position overnight for 12 hours. The letter also stated she tries to limit fluid intake and has to hold her bladder in order to try to not soil herself when the PCA is not present. Her physical medicine and rehabilitation physician wrote a letter stating 24 hour split-shift PCA services are required as she is need of active help overnight with transfer assistance, assistance to/from bathroom, assistance with shifting and repositioning in bed overnight. The letter also stated the patient is experiencing excessive pain and unsanitary conditions at night and that her proximal muscles continue to weaken due to progressive nature of her illness.

The health plan's determination is overturned in whole.

The patient had been employed and did not require PCA service hours during the hours of her job and during that time of employment the patient had 24 hours of PCA services on the days she did not work (Saturday and Sunday). The patient was not able to continue to work due to issues related to her previous femur fracture and because she has no informal helper, requires 24 hour PCA services. In addition, her medical provider noted her condition to be progressive which will lead to an increase in assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) over time. Her medical provider also noted the patient required 24 hour split-shift PCA services due to her need for assistance with transfer, toileting, shifting and repositioning all of which are required during the 12 hours the patient does not have PCA services. Her PCA service needs are not solely for companionship and safety/supervision but to assist the patient with completing ADL tasks and shifting and repositioning for pain and to prevent skin breakdown/infection. Split-Shift is medically necessary as the patient's care needs would prevent the aide from obtaining 5 hours of uninterrupted sleep. Furthermore, the patient's last assessment tool was performed prior to the patient not working Monday through Friday when she did not require 24 hour assistance Monday through Fridays.