Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-hip fracture
Treatment: Home Health Care 
The insurer denied an increase in PCW services. 
The denial was upheld. 

The patient is a female with a past medical history significant for Alzheimer's disease, mood disorder, coronary artery disease, anxiety, and depression. She had a recent fall and suffered a hip fracture treated with percutaneous pinning. She had an acute hospitalization and subsequently was transferred to rehab. The patient has currently been approved for 6 hours a day times () 7 days a week for a total of 42 hours a week. Services were denied based upon medical necessity.

According to her plan, services were denied based upon the following rationale, "You are minimally impaired, your procedural memory is okay. You are alert and oriented to yourself in place with forgetfulness. You can ambulate, transfer, and use a toilet with limited help and without the use of an assistive device. You can move on and off the toilet with limited assistance. You can feed yourself with the meals prepared for you in advance and set up by your personal care worker." The patient is appealing this decision.

In the appeal letter it states that the patient will need increased assistance with activities of daily living (ADLs) such as walking, transferring, and using the toilet due to her decreased mobility. Tasking tool notes a total of 28.9 hours a week. Uniform Assessment System (UAS) State of New York notes limited assistance with locomotion transfer and toilet use.

At issue is an increase in Personal Care Worker (PCW) service to 7 days per week, 10 hours per day, 70 hours per week.

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

The requested health service of increase in Personal Care Worker (PCW) service to 7 days per week, 10 hours per day is not medically necessary for this patient. Documentation did not support the need for additional service hours beyond the hours which were currently approved for the patient. Tasking tool indicated that 4.1 hours per day of service was sufficient to meet the patient's needs. The patient has a medical history significant for Alzheimer's disease with cognitive impairment. She has had progressive decline in her cognitive impairment. She also suffered a fall resulting in a left hip fracture and subsequent percutaneous pinning of her left hip. She was treated in acute hospitalization and subsequently referred to skilled services for rehab. There was no official new UAS noted for evaluation. The previous one was done prior to her fall. However, physical therapy note states that the patient performed bed mobility with minimal assistance, transfers with minimal assistance and side steps 2-4 steps using a roller walker with minimal assistance.

Her functional evaluation comparing physical therapy notes from the hospitalization versus prior to hospitalization were consistent in her levels of disability. Physical therapy notes showed minimal assistance which were similar to those provided by UAS. Therefore, significant functional decline is not noted. Additional services are not noted to be necessary in regard to the patient's recent hospitalization. Documentation provided supports 7 days per week, 6 hours per day for 42 hours a week of services. The aide services the patient has currently included help with cooking, shopping, housekeeping, bathing, and personal hygiene. Safety monitoring, supervision and cognitive prompting are not by themselves independent or standalone instrumental activities of daily living (IADLs), ADLs, or tasks. More hours for supervision purposes are not medically necessary.

Therefore, the requested health service of increase in Personal Care Worker (PCW) service to 7 days per week, 10 hours per day is not medically necessary.