Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System. 
Treatment: Home Health Care. 

The insurer denied the Personal Care Assistance 24 hours per day, split shift, 7 days per week. The denial is overturned in whole. 

The patient is a female with a past medical history of alzheimier's dementia, bladder incontinence, bowel incontinence, aortic valve stenosis, diabetes mellitus type 2, osteoarthritis and pressure ulcers who lives in a one bedroom apartment alone and had a fall with hip fracture with no required surgical intervention. The patient's primary care physician (PCP) provided a letter stating the patient has longstanding dementia with behavioral disturbances and hallucinations and would benefit from having another separate aide present from 8 pm to 8 am to help with activities of daily living (ADL) and prevent a catastrophic fall. The patient's neurologist provided a letter to the insurer stating her diagnosis of dementia and that her recent fall had occurred during the night when a home health aide was not present. It also stated that due to her dementia she is often awake and agitated at irregular times requiring constant need for supervision and care and is now bedbound with multiple pressure ulcers which require frequent repositioning and tending. During an assessment the documentation assessed the patient a total assistance for tasks of meal preparation, ordinary housework, managing finances, stairs, transportation, shopping and equipment management and maximum assistance with managing medication and phone use. For tasks of bathing, personal hygiene, dressing upper/lower body, transfer toilet and toilet use the patient was assessed at extensive assistance while independent with bed mobility and eating. The patient was admitted to hospice with documentation the patient was cachectic, had significant decline in status since the fall, has poor by mouth intake and sometimes refuses to eat, has lost 20 pounds, has been bedbound, is dependent on all ADLs and has multiple pressure ulcers on bilateral heels and partial-thickness wound to the sacrum. The patient's PCP provided another letter stating the patient is completely bedbound with pressure ulcers requiring frequent repositioning and tending. The health plan's determination is overturned. 

The patient had a hip fracture with subsequent decline in her physical and mental capabilities due to this fracture and dementia leading to less activity and eventual bedbound status. The patient developed sacral and heel ulcers requiring repositioning and turning on a regular basis in the overnight hours. This requirement would not allow a personal care aide to obtain 5 hours of uninterrupted sleep. In addition, the patient lives in a one-bedroom apartment which is not sufficient to provide space for a live-in personal care aide. There is documentation from her neurologist and her PCP noting the medical necessity of repositioning and turning. The telephonic assessments were performed for the patient's personal care needs. Overnight PCA service hours are not solely for supervision and safety but to assist the patient with ADL's current. It is medically necessary for the patient to have 24 hour PCA service care, split shift, due to her need for frequent repositioning and the lack of space in her one-bedroom apartment for a personal care aide. 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. As stated above the personal care services are medically necessary at 24 hours per day, split shift, 7 days per week.