Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied increase in PCA hours to 24 hours a day split shift, 7 days per week. 
The denial is overturned in whole.

The patient is a female with past medical history of osteoarthritis of multiple joints, spinal stenosis, oxygen dependent chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), hypertension, dementia, fecal urgency, urinary incontinence, unsteady gait, frequent falls and gastroesophageal reflux disease (GERD) who had been assigned personal care assistant (PCA) services hours 12 hours/day, 7 days/week to total 84 hours/week based on assessment tool performed at the end of the year. This assessment noted the patient to need total assistance for tasks of ordinary housework and stairs while maximum assistance with tasks of meal preparation, shopping, dressing lower body and toilet use. The patient was assessed at extensive assistance for tasks of managing finances, phone use, transportation, equipment management, bathing, personal hygiene, dressing upper body, walking, locomotion and transfer toilet while limited assistance with tasks of managing medication and bed mobility. The patient was assessed as independent with task of eating. The assessors notes stated the patient lives in a two bedroom apartment, walks with walker with hands on assist, is occasionally incontinent and has informal helper who is her daughter who is able to sleep over most nights.

The patient had change in functional status following a hospitalization 4 months prior with request to increase PCA service hours and another assessment tool was performed over the telephone. The patient was assessed at total assistance for tasks of meal preparation, ordinary housework, stairs, shopping, transportation, locomotion and toilet use while assessed at maximum assistance for tasks of managing finances, managing medication, phone use, bathing, personal hygiene, dressing upper/lower body. Tasks of equipment management, walking and transfer toilet did not occur as it was noted patient was bed bound and not able to sit up in bed. However, the patient was assessed at extensive assistance for tasks of bed mobility and eating. The assessor noted the patient is very forgetful with periods of confusion, declined in mental and body function, is weaker and frail, is bed bound, unable to sit up or change position by herself, requires repositioning every two hours, has difficulty feeding self, has frequent incontinence of bladder and occasional incontinence of bowel. The patient's primary care physician (PCP) provided a letter stating the patient's medical diagnoses and the patient is bed bound and requires 100% assistance with her activities of daily living (ADLs). 

The increase in hours to 24 hours per day split shift 7 days per week is medically necessary for this patient. The patient had a hospitalization four months prior with significant change in functional status requiring increase PCA service needs. The patient is now bed bound and per doctor order, requires turning and repositioning every two hours and has unscheduled nighttime incontinence care needs of at least three times per night. The need for turning and repositioning and ADL assistance with unscheduled nighttime tasks would not allow for a live in aide to obtain five hours of uninterrupted sleep which would necessitate split-shift PCA care. The patient's overnight needs are not solely for safety and supervision but to assist the patient with overnight ADL's. The patient's assistance needs span a 24 hour period, therefore task based assessment tool cannot be utilized to determine PCA service hours. Based on information provided regarding the patient, PCA service hours 24 hours/day, split-shift, 7 days/week are medically necessary for this patient.