Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Bone Fracture/Break
Treatment: Home Health Care/PCA
The health plan denied the increase in PCA services as not medically necessary. 
The reviewer has overturned in whole the health plan determination.

The patient has a past medical history of diabetes mellitus type 2 on insulin, hypothyroidism, cirrhosis, morbid obesity, coronary artery disease, congestive heart failure, atrial fibrillation on anticoagulation, sleep apnea on continuous positive airway pressure, incontinence of bowel and bladder, osteoarthritis, osteoporosis, vascular dementia, recurrent urinary tract infections, TIA, history of pressure ulcers, history of multiple falls, chronic oxygen therapy, osteomyelitis of right foot, right hip fracture, home bound and bedbound, who had been assigned PCA services 24 hours/day, live-in, 7 days/week. The patient had a hospitalization in the spring of this year following a fall with injury to foot with wound developing osteomyelitis requiring skin graft with hospitalization and rehabilitation stay to total 80 days with discharge to home. Following this hospitalization and rehabilitation stay the patient was mostly bed bound and was on chronic oxygen via nasal canula.
Office note from the primary care physician noted the patient had a Hoyer lift, hospital bed, and reclining wheelchair in the home and needed to be turned and repositioned every two hours. 

The patient was hospitalized and diagnosed with UTI and found to have a right femur fracture possibly from an earlier fall. The patient was not felt to be an operative candidate for the hip fracture. The patient had an assessment tool performed following discharge due to request to increase PCA service hours to 24 hours/day, split-shift, 7 days/week and patient was assessed at total assistance for ordinary housework, stairs, transportation, locomotion and transfer toilet while maximum assistance with tasks of meal preparation, shopping, bathing, dressing lower body, toileting and bed mobility. The patient was assessed at extensive assistance for managing finances, managing medication, phone use, equipment management, personal hygiene, dressing upper body while limited assistance with task of eating. The assessment notes stated the patient was bedbound and could not bear weight on  feet due to femoral fracture and patient was out of bed with Hoyer lift.

The patient sustained a right hip fracture that was non-operable. The patient was bedbound and not able to walk, turn or reposition in bed, get on and off the urinal, provide incontinence cares or perform personal hygiene without the help of PCA's. The patient's assessment tool performed on should not  be used to calculate her PCA aide hours, as the patient has unscheduled and unpredictable needs throughout a particular span of time. The patient's PCP noted medical necessity for turning and repositioning every two hours (actually dating back several months) to prevent pressure ulcers. The patient also takes a diuretic increasing the need for incontinence cares which are unscheduled and unpredictable over 24 hours. The patient's PCA service hours are not solely for supervision and safety but to assist the patient with ADL's and IADL's. There is clear documentation of medical necessity by her physician of split-shift PCA hours due to overnight needs which include turning and repositioning every two hours as well as incontinence cares. The patient's overnight needs would not allow a live-in PCA to obtain 5 hours of uninterrupted sleep. 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.