Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip fracture. 
Treatment: Increase in PCA (personal care aide) services: Total of 56 Hours per Week (8 Hours per Day, 7 Days per Week). 

The insurer denied Increase in Personal Care Aide (PCA) Level 2 Services: Total of 56 Hours per Week (8 Hours per Day, 7 Days per Week). The health plan's determination is overturned. 

The patient is a male with past medical history of coronary artery disease, hypertension, congestive heart failure, hyperlipidemia, prostate cancer, glaucoma, gastrointestinal (GI) bleed, anemia, dementia, osteoarthritis, urinary incontinence, and skin cancer who had been assigned PCA (personal care aide) services following an assessment tool. The patient was assessed at maximal assistance with tasks of meal preparation, ordinary housework, and shopping and extensive assistance with tasks of managing finances, managing medication, bathing, and dressing lower body. The patient was assessed at limited assistance with tasks of phone use, stairs, transportation, dressing upper body, walking, locomotion, and toilet use and supervision with task of transfer toilet. With tasks of personal hygiene, bed mobility, and eating the patient was assessed as independent. The patient had a fall requiring hospitalization with diagnosis of right hip fracture and myocardial infarction. The patient had open reduction internal fixation (ORIF) of the right hip and subsequent transfer to rehabilitation. There was a request to increase PCA services. 

The Increase in Personal Care Aide (PCA) Level 2 Services: Total of 56 Hours per Week (8 Hours per Day, 7 Days per Week) is medically necessary. 

The patient had a change in functional and mental status following a fall with fracture of the hip requiring surgery. In addition, the patient has progressive medical illnesses of osteoarthritis and dementia. The patient had and increase in assistance needs with multiple tasks, specifically with tasks of meal preparation, ordinary housework, phone use, stairs, shopping, transportation, bathing, personal hygiene, dressing lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient's increase in assistance needs cannot be met with adaptive equipment and supplies only. The patient requires assistance with all tasks except eating. The patient has unscheduled and unpredictable care needs that span a continuum of time and the patient would need PCA assistance outside of the hours the patient's informal helper is available. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 8 hours/day, 7days/week, to total 56 hours/week 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 his own home.