Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an increase in personal care hours to 2 shifts, 12 hours per day, 7 days a week split-shift totaling 168 hours/week. 
The denial was overturned in whole.

The patient is a female with past medical history of dementia, atherosclerotic heart disease, osteoporosis with multiple compression fractures, radiculopathy, hand osteoarthritis with severe hand deformities, urinary incontinence and balance impairment. The patient had a telephonic assessment noting patient is not able to direct her care, has had cognitive decline since hospitalization, is not able to get up or turn herself in bed without the assistance due to muscular weakness, has become mostly bed bound, needs to be spoon fed due to her arthritis with hand deformity, requires maximum assistance with sponge baths, upper body dressing, and toileting and requires total assistance with socks/shoe dressing. The assessment noted the patient sleeps with her mouth open and when she awakes needs help getting a drink. A worksheet assessment answered "yes" if the member had nighttime needs and indicated nighttime needs were toileting and safety concerns. The patient tends to lose balance and cannot stand for a long time and is at high risk for falls. In addition, the patient cannot eat, drink or use commode on her own due to the arthritic deformed hands and has to be fed, given fluids and assisted with commode and hygiene needs as she cannot hold utensils and cups on her own or clean herself. Because of pain she has limited ability to move around by herself due to deforming and degenerative arthritis of the spine with bilateral radiculopathy and needs maximum assistance around the clock to transfer from her bed which she spends most of the time. She has erratic sleep and wake times, gets confused, agitated and paranoid at times with the need to be reoriented and monitored at times with her needs and requests are unpredictable and unscheduled. The patient is not able to urinate or have a bowel movement when lying in bed and asks to be transferred to commode, needs to be assisted with lifting her legs and turning side to side, needs to be monitored on commode because she cannot stand up on her own. The patient needs to be thoroughly cleaned and dried following commode use to prevent infection, uses the commode every 3 to 3.5 hours overnight, needs to be turned to the side and re-positioned every 2 hours to prevent decubiti, pressure ulcers and bedsores. Overturn, in whole, the health plans determination of medical necessity. Yes, the requested personal care worker service 2 shifts 12 hours per day 7 days week split shift totaling 168 hours per week is medically necessary. The patient has significant arthritis of the spine and hands making her unable to transfer and turn in bed or eat and drink without assistance. Per the documentation provided the assessment incorrectly noted the patient had assistance from family in the overnight hours. This assessment also incorrectly stated the patient's daughter lives in the same building as the patient. The patient's PCP documented the patient's nighttime needs for toileting every 3-3.5 hours and the need to turn and re-position every 2 hours to prevent skin breakdown and infection. A mattress pad does not replace the need for turning and repositioning. The patient does not have informal helper. The patient's PCA hours are not solely for safety and supervision but to assist the patient with overnight activities of daily living (ADL's) instrumental activities of daily living and (IADL's). Due to the patient's overnight personal care needs the patient's aide would not be able to obtain 5 hours of uninterrupted sleep. Therefore, the service is medically necessary in this case.