Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis.
Treatment: Increase in home care/personal care / home health care (HHC) - personal care aide live-in - mutual increase to 24 hours per day (split-shift).

The insurer denied an increase in home care/personal care / home health care (HHC) - personal care aide live-in - mutual increase to 24 hours per day (split-shift).  The determination is overturned.

The patient has a past medical history of dementia, osteoarthritis, congestive heart failure, and major depressive disorder. The patient was assigned services based on an assessment assessing the patient as minimally impaired with no memory problems. She was assessed to require total dependence with the tasks of meal preparation and housework, and extensive assistance with medications. The patient was assessed at maximal assistance with the task of bathing, extensive assistance for personal hygiene, extensive assistance for dressing upper body and maximal assistance for dressing lower body, extensive assistance with walking and extensive assistance with toilet use and transfers, limited assistance with bed mobility and limited assistance with eating. She is occasionally bladder incontinent and bowel continent. She was noted to be ambulating with a walker. The patient was assessed to require 31 hours of assistance weekly.
She had undergone an assessment for PCA (personal care assistant) services assessing the patient as minimally impaired with no memory problems. She has no hearing and no vision difficulties. She requires maximal assistance with the tasks of meal preparation, and medications. The patient was assessed at extensive assistance with the task of bathing, limited assistance for personal hygiene, limited assistance for dressing upper body and extensive assistance for dressing lower body, limited assistance with walking and limited assistance with toilet use and transfers, independent with bed mobility and independent with eating. She is infrequently bladder incontinent and bowel continent. She is noted to be ambulating with a walker. The assessment was done while the patient was at a nursing facility and assessed to require 23 hours of assistance weekly
The patient's primary care provider wrote a letter of medical necessity. The physician noted that the patient has multiple medical problems including congestive heart failure, severe osteoarthritis and dementia. The physician noted that the patient is bedbound and is completely dependent for activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The physician also stated that the patient is unable to turn in bed independently and would benefit from an increase in hours for home care to ensure safety and stability.

Review is regarding the medical necessity of an increase in home care / personal care / home health care (HHC) - personal care aide live-in - mutual increase to 24 hours per day (split-shift). 

The requested health service/treatment of home care / personal care / home health care (HHC)- personal care aide live-in - mutual increase to 24 hours per day (split-shift) is medically necessary for this patient.

Based on the assessment, the patient was noted to require assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) and noted to require limited assistance with toilet use and transfers, however, per the primary care physician's documentation, the patient is completely dependent, bedbound and requires assistance with transfers and bed mobility, and also has severe osteoarthritis limiting movement. The assessment was completed at a nursing facility and not the patient's home. Given that the patient is incontinent and needs assistance with turning additional hours are necessary.

The patient currently has 24 hour live-in personal care services with care provided by 1 care aide for assistance with ADLs throughout the day who will not be able to have 5 hours of interrupted sleep, given that the patient requires assistance during nocturnal hours as well for positioning and toileting, the patient requires assistance in the overnight hours as well, and will be better served with a personal care assistant for the nocturnal hours. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, personal care HHC- personal care aide live-in - mutual increase to 24 hours per day (split-shift), is medically necessary for this patient.