Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe degenerative joint disease, rheumatoid arthritis osteoporosis related to long-term steroid utilization with numerous osteoporotic fractures, heart failure, and quadriplegia.
Treatment: Increase Personal Care Services (24 hours per day, split shift {two 12-hour shifts}) 7 days per week)
The insurer denied: Increase Personal Care Services (24 hours per day, split shift {two 12-hour shifts}) 7 days per week)
The denial is overturned.

The patient is an adult female with severe degenerative joint disease, rheumatoid arthritis osteoporosis related to long-term steroid utilization with numerous osteoporotic fractures, heart failure, and quadriplegia. She is bed-bound. The request is for 12/12 hours split shift home care. Previously, personal care services were approved for 12 hours per day, 7 days a week.
A home assessment 5 months ago noted help with meal preparation, housekeeping, shopping, laundry, bathing, toileting, dressing, personal hygiene, eating. There was the utilization of a walker and a wheelchair for ambulation. Objectively, the following were noted: Maximum assistance with meal preparation, total dependence with ordinary housework performance capacity, extensive assistance with performance in capacity of finance management, extensive assistance with performance and capacity medication management, limited assistance with performance and capacity of phone utilization, total dependence with performance and capacity of transportation, maximum assistance with bathing, extensive assistance with personal hygiene, extensive assistance with upper body dressing, maximum assistance with lower body dressing, maximum assistance with locomotion, maximum assistance with toilet transfer, maximal assistance with toilet use, extensive assistance with eating.

The requested health service is medically necessary.

A home assessment 5 months ago noted help with meal preparation, housekeeping, shopping, laundry, bathing, toileting, dressing, personal hygiene, eating. There was the utilization of a walker and a wheelchair for ambulation. Objectively, the following were noted: Maximum assistance with meal preparation, total dependence with ordinary housework performance capacity, extensive assistance with performance in capacity of finance management, extensive assistance with performance and capacity medication management, limited assistance with performance and capacity of phone utilization, total dependence with performance and capacity of transportation, maximum assistance with bathing, extensive assistance with personal hygiene, extensive assistance with upper body dressing, maximum assistance with lower body dressing, maximum assistance with locomotion, maximum assistance with toilet transfer, maximal assistance with toilet use, extensive assistance with eating. It was noted that her needs could be met with services provided 12 hours/day x 7 days. However, further appeal noted that secondary to her quadriplegia and her multiple comorbidities, including intermittent edema related to heart failure, the patient's skin integrity is at high-risk requiring frequent assisted repositioning during the day as well as night. This is for the prevention of skin breakdown and pain alleviation related to severe degenerative joint disease. However, the analgesic regimen has been inadequate to treat the current pain, necessitating frequent repositioning every 2 hours by an aide. Furthermore, secondary to persistent fecal/urinary incontinence, she requires further help, exacerbated by her quadriplegia and inability to move around. Given that the patient needs exceed the capabilities that can be provided during the day, she requires night assistance as well. Therefore, given the above, the requested increase in personal care services to 24 hours per day, split shift, is medically necessary.