Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied Personal Care Aide 7 days x 12 hours x 2 shifts. 
The denial is upheld. 

The patient is a female with a past medical history significant for vascular dementia, hypertension, proximal supraventricular tachycardia, and osteoporosis. She had a recent fall resulting in a hip and shoulder fracture. The patient was treated conservatively, nonoperatively. Her injuries did not require surgical intervention. She was sent to a skilled care for rehabilitation and subsequently discharged home. It was stated that the family was available at the time the aide leaves until morning. The family also had another sibling at times doing night shifts. Tasking tool noted no additional nocturnal needs. 
Services were denied by her health plan for services of Personal Care Aide 7 days a week times (x) 12 hours x 2 shifts, stating that the patient does not meet criteria. The patient is appealing the decision.
At issue is the medical necessity of Personal Care Aide 7 days x 12 hours x 2 shifts.

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

The requested health service of Personal Care Aide 7 days x 12 hours x 2 shifts is not medically necessary for this patient.

There must be a documented need for continuous uninterrupted nighttime care relating to the patient's functional needs. Based upon review of clinical records, there are no documented changes that indicate the patient requires nighttime uninterrupted care. The patient's nighttime needs of toileting can be met with appropriate durable medical equipment and/or incontinence supplies. Nighttime needs such as fall prevention, forgetfulness and wandering are not related to Instrumental activities of daily living (IADL)s and are for safety and supervision. The patient is an elderly female admitted to the hospital for a fracture of her right pubic rami and also shoulder fracture. The patient was treated conservatively. Her injuries did not require surgical intervention. She was sent to skilled care for rehabilitation and subsequently discharged home. The patient did have a significant change in her health status with a recent fall, pubic rami fracture and shoulder fracture. This can significantly limit independence in elderly patients. However, the patient did have an evaluation by her physician this year, noting the following: that the patient can walk without assistance, she does need assistance at times to stand. She typically goes to bed for 12-14 hours a day, there is no wandering, agitation or need for urinating at night. She typically uses provided incontinence products. There is no mention of other nighttime needs such as bedsores or other needs for frequent turning in the middle of the night.
The patient's medical needs, IADLs and activities of daily living (ADL)s are provided for an allotted time. There is no specific other ADLs or IADLs noted to be medically necessary at night, as documented through the patient's physicians recent assessment. When approving services, there must be a demonstrated need for ADLs or IADLs above and beyond observation and preventing falls. Specifically, the aide must be performing a service such as in ADL or IADL. Aide services for watching the patient in the middle of the night without actually performing a medically necessary ADL would be considered observation and typically not a service provided. The documentation provided did not note a specific need for 12 hours a day  7 days a week split shift.
Therefore, the requested health service of Personal Care Aide 7 days x 12 hours x 2 shifts is not medically necessary.