Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Home Health Care

Diagnosis: Orthopedic/Musculoskeletal-Osteoarthritis
Treatment: Home Health Care-Personal Care Aid (PCA) services
The health plan denied an increase in PCA services to 2 12 hour split shifts as not medically necessary. The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history of cerebrovascular accident (CVA), hypertension, atrial fibrillation, coronary artery disease, hyperlipidemia, chronic pain due to osteoarthritis of the knees and hips, tremor, gastroesophageal reflux disease (GERD), osteoporosis, and urinary incontinence who had been assigned Personal Care aid (PCA) services 42 hours/week based on assessment performed assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, and toilet use. With tasks of managing finances, managing medication, phone use, and transfer toilet the patient was assessed at limited assistance while supervision with task of eating. The patient was assessed and independent with the task of bed mobility. The patient had a CVA with left-sided hemiplegia with hospitalization and subsequent transfer to rehabilitation. The patient also had COVID infection during hospital stay. The patient underwent another assessment in preparation for discharge from rehabilitation assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, and shopping while maximum assistance with tasks of managing finances, managing medication, transportation, bathing, personal hygiene, dressing upper/lower body, locomotion, and toilet use. The patient was assessed at extensive assistance with task of phone use, bed mobility, and eating and it was noted activities of walking and transfer toilet did not occur during the assessment. Notes from the assessment stated the patient had a decline in activities of daily living (ADL) status and a deterioration of overall self-sufficiency in the last 90 days and the patient's closest relative lived in Pennsylvania. The patient now had worsening urinary and fecal incontinence. The patient's medical provider sent a letter requesting an urgent increase in hours of home care due to the patient's rapidly deteriorating mental state, physical health, and functional status. The provider also noted the patient had rapidly progressing dementia with disorientation, hallucinations, depression, aggression, loss of appetite, and poor hygiene habits. Lastly, the provider stated that they recommended and believed it was very important and medically necessary for the patient to have 2 split shifts of 12 hours of home care daily and nightly, 7 days/week. 

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient. Although the patient has documented decline in cognitive and physical functioning following CVA 1/2023, there is no documentation of specific overnight assistance needs that would not allow PCA 5 hours of uninterrupted sleep. There are no overnight care logs with documentation of assistance needs with ADLs with specific times. The plan appropriated increased PCA services to 24 hours/day, live-in, 7 days/week from 42 hours/week. The approval of split-shift services would be for safety and supervision which is not a covered benefit. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, are not medically necessary for this patient.