Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Home Health Care-PCA-Other
The health plan denied the increase in PCA services as not medically necessary. The reviewer overturns the health plan's denial in whole. 

The patient is elderly and lives with an elderly wife, with past medical history of chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, atrial fibrillation, hypertension, hyperlipidemia, hearing loss, vision loss, rheumatoid arthritis, neuropathy, spinal compression fractures, bilateral hip replacements, chronic pain, instability of gait, multiple falls, major depressive disorder and memory loss who had been assigned 4 hours/day, 7 days/week to total 28 hours/week of PCA services based on an assessment tool performed. The patient had a fall 3 months later with resultant pelvic fracture and left hip fracture with subsequent open reduction internal fixation of the left hip and transfer to rehabilitation center. When planning for discharge from rehabilitation stay, it was felt by the provider, physical therapy, and occupational therapy that the patient would need an increase in PCA service hours to 24 hours a day. There was a request for this increase in PCA service hours.

The patient's neighbor provided a letter stating that prior to pelvic fracture and hip fracture he had had to physically assist the patient multiple times, specifically at least 30 times over the last year. The patient has also had police and fire response to the home in order to have help with falls. The wife's primary care provider (PCP) provided a letter stating that she is physically unable to care for her chronically ill husband. The patient's PCP provided a letter stating the patient's medical diagnoses, side effects from medication, and an increase for constant prolonged assistance with ADLs (activities of daily living). The letter specifically stated that the patient needed 24 hour aide services. 

Prior to the patient's fall, the patient had multiple episodes of falls and need for help with transferring resulting in his neighbor and fire and police authorities having to assist the patient. The patient did not have an informal caregiver as his wife was unable to assist him with ADLs because of her own health issues. The patient had a subsequent decline in his physical condition with a fracture of the pelvis and hip and although there was documentation that he was able to ambulate 300 feet with an assistive device, the patient required assistance with walking, locomotion, transfer toilet and toilet use, which are unscheduled and unpredictable care needs over a particular span of time. PCA service hours are not solely for supervision and safety but to assist the patient with ADLs and IADLs (instrumental activities of daily living). The patient's previous universal assessment done does not account for the patient's current PCA care needs for multiple tasks, given his decline in physical condition with the pelvis and hip fractures. 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 his own home. The patient's neurologist and PCP have documented medical necessity of 24-hour PCA services, 7 days per week, live-in.