Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an increase in personal care hours to 24 hours a day split-shift, 7 days a week. 
The denial was overturned in whole. 

The patient is a female with a past medical history of seizure disorder, depression, urinary incontinence, bowel incontinence, absence of left hip joint, and abnormality of gait. She had been hospitalized with complications related to her hip with infection requiring insertion of a cement spacer and need for intravenous (IV) antibiotics. Notes from the  assessment noted the patient lived with her daughter and son in law, had a non-healing open wound to the left hip, was now non ambulatory, wore pull ups for urinary incontinence, daughter assisted with administration of IV antibiotics, and the patient needed assistance at night with toileting.
The patient was hospitalized again with revision of left total hip with insertion of a new total left hip. The patient was transferred to rehabilitation. The patient's occupational therapist provided a letter stating the patient needed minimal/moderate assistance with bed mobility, transfer status remained at maximum assist of two people with wheelchair to follow, required minimal/moderate assist in upper body dressing/grooming, required moderate/maximum assistance with toileting, and maximum assistance with lower body dressing and bathing. The letter lastly stated that the occupational therapy (OT) and physical therapy (PT) therapists were recommending twenty-four hours of home care assistance upon discharge.
The plan sent a final adverse determination denial notice stating denial of request to increase PCA services.
The patient's health care advocate provided request for external appeal on behalf of the patient. 

At issue is the medical necessity of an increase in personal care services, 24 hours a day split-shift, 7 days a week (two 12-hour shifts).

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

The requested health service/treatment of increase in personal care services, 24 hours a day split-shift, 7 days a week (two 12-hour shifts) is medically necessary.
The patient has documented chronic medical conditions including multiple complications from a prior left hip replacement with spacer placement and subsequent new left hip replacement. There is documented decline in physical functioning with noted need for assistance with activities of daily living (ADL)s. The patient's house call physician and orthopedist recommended an increase in PCA hours to 24 hours per day. The patient has overnight needs documented by overnight care logs in which a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The patient requires assistance with all ADLs/ Instrumental activities of daily living (IADL)s. The patient has unscheduled and unpredictable care needs over 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 requested increase in PCA hours is not solely for supervision and safety but to assist the patient with safe completion of ADLs/IADLs. Taking into account all information provided regarding the patient, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7days/week, are medically necessary. 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 increase in personal care services, 24 hours a day split-shift, 7 days a week (two 12-hour shifts) is medically necessary.