Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 

The insurer denied Increase in Personal Care Services (PCS)- 24 hours x 7 days a week (split shift). 
The denial is overturned in whole. 

The patient is a female with a past medical history of Parkinson's disease, diabetes mellitus type 2, hypertension, bladder incontinence, bowel incontinence, hyperlipidemia, gastroesophageal reflux disease (GERD), coronary artery disease, atrial fibrillation, mood disorder, chronic obstructive pulmonary disease (COPD), diabetic neuropathy, inflammatory polyarthropathy, hemiplegia, and sciatica, who had been assigned personal care assistance (PCA) services 9 hours/day, 7 days/week, to total 63 hours/week. There was a request to increase PCA services. The patient's primary care physician (or provider) (PCP) provided a letter stating the patient had worsening of dementia and Parkinson's disease and required assistance with all daily activities and needed an increase in her home aide service hours.
The patient underwent assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, bathing, dressing upper body, and toilet use while maximum assistance with tasks of managing medication, phone use, equipment management, personal hygiene, and bed mobility. The patient was assessed at extensive assistance with task of eating. With tasks of walking, locomotion, and transfer to the toilet the patient was not assessed as it was noted the activity did not occur. Notes from the assessment stated the patient temporarily lived with her son and had moderately impaired cognitive skills. 
The insurer sent final adverse determination denial notice denying request to increase PCA services stating it was not medically necessary and the patient did not meet criteria. The denial recommended the patient talk to her PCP about a referral to physical therapy and occupational therapy. The insurer denial recommended the patient split her schedule into two shifts to help meet her morning and evening needs and safety supervision is not a covered service under the patient's benefit plan. Lastly, the denial stated there was no medical need for the patient to get up at night and overnight services would be for safety supervision.
At issue is the medical necessity of Increase in Personal Care Services (PCS)- 24 hours times (x) 7 days a week (split shift).

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

The requested health service/treatment of Increase in Personal Care Services (PCS)- 24 hours x 7 days a week (split shift) is medically necessary for this patient.
The patient's medical provider documented medical necessity of increased PCA services. The patient is incontinent of bowel and bladder. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The insurer assumed the patient had informal help from family and failed to document a plan to meet the needs of the patient outside of informal help. 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, 7 days/week (split-shift) 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.
Therefore, the requested health service/treatment of Increase in Personal Care Services (PCS)- 24 hours x 7 days a week (split shift) is medically necessary.