Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Clavicle fracture
Treatment: Personal care aide
The insurer denied Personal Care Aide Level 2: 12 Hours per Day, 7 Days per Week (Total of 84 Hours per Week). 
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, gastroesophageal reflux disease (GERD), hypothyroidism, hyperlipidemia, congestive heart failure, and a recent clavicle fracture. The patient had telephonic assessment with subsequent increase in PCA (personal care aide) hours to 6 hours/day, 7 days/week to total 42 hours/week. The patient had a fall with clavicular fracture with two day hospital admission. The patient was subsequently sent to rehabilitation with discharge to home. Notes from rehabilitation discharge stated the patient required minimal to moderate assistance with ambulation due to poor/fair balance, touching assistance to minimal assistance with transfers, supervision with toileting, moderate assistance with bed mobility, moderate assistance with bathing, and contact guard assist to dress upper body and lower body. A recent telephonic assessment noted that the patient lived downstairs from her granddaughter but her granddaughter was an emergency room nurse who worked 12.5 hour shifts and was not available to assist the patient during the day. The patient had increased assistance needs with dressing upper body (total assistance, previous extensive assistance), dressing lower body (maximum assistance, previous extensive assistance), walking (maximum assistance, previous extensive assistance), locomotion (total assistance, previous extensive assistance), eating (set up, previous independent), and bed mobility (maximum, previous supervision).

Personal Care Aide Level 2: 12 Hours per Day, 7 Days per Week (Total of 84 Hours per Week) are medically necessary for this patient.

The patient had documented loss of function related to a new clavicular fracture with an inability to be surgically corrected. The patient also had documented increase in assistance needs with multiple tasks and the insurer failed to document a plan to meet these needs. The patient does not have formal or informal help for at least 12 hours/day and requires assistance with activities of daily living (ADL) during the time she does not have formal or informal help. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met with the current PCA hours and/or adaptive equipment and/or medical supplies. The requested 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 12 hours/day, 7 days/week, to total 84 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 her own home.