Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Orthopedic/Musculoskeletal. 
Treatment:  Home Health Care; increase in personal care aide hours to 7 days x (2) 12 hour split shifts. 

The insurer denied the Increase in personal care aide hours to 7 days x (2) 12 hour split shifts.  The denial is overturned in whole.

The patient is a female with past medical history of post-polio syndrome with paraplegia, bowel and bladder incontinence, glaucoma, osteoporosis, insomnia, hearing loss, hyperlipidemia, seizure disorder, diabetes mellitus (DM) type 2, obesity and remote history of breast cancer, who had been assigned personal care aide services 24 hours/day, live-in, 7 days/week.  There was a request to increase service hours to 7 days x (2) 12 hour split shift.

The Uniform Assessment System - New York Comprehensive Community Assessment Report assessment the patient was assessed at total assistance for meal preparation, ordinary housework, stairs, shopping, transportation, bathing and toilet use, and she was assessed at maximal assistance with tasks of managing finances, personal hygiene, dressing upper/lower body, locomotion and bed mobility.  The patient was assessed at extensive assistance for tasks of equipment management and limited assistance with tasks of managing medication, phone use and eating.  The assessment noted the patient had a Hoyer lift, hospital bed and scooter in her home and was wheelchair bound.  It also noted the patient was totally dependent for incontinence cares and was unable to reposition herself in bed, needing turning and positioning every 2-3 hours.  The patient's most recent assessment noted the patient to be total assistance with tasks of ordinary housework, managing finances, stairs, shopping, transportation and toilet use and maximal assistance with tasks of bathing, dressing lower body and locomotion.  The patient was assessed at extensive assistance with tasks of managing medications, equipment management, personal hygiene, dressing lower body and bed mobility while independent with tasks of meal preparation and eating.  This assessment noted the patient lives alone and has hospital bed with over bed table.  Overnight logs documented the patient needed diaper change at 12 a.m. and was awake and calling aide frequently, and the patient needed "help" at 11 p.m. and was awake and asking for the same thing over and over again every 5 minutes.  The aide had no sleep either night.  The patient's primary care physician (PCP) provided a letter stating the patient needed 24-hour care in two 12 hour shifts.  The note stated the patient had been bed bound for a prolonged period and has history of paraplegia with poliomyelitis and multiple falls with fractures, and her clinical conditions have recently deteriorated with progressive disorientation, skin ulceration, insomnia and agitation, which is most prominent at night, with transition to functional quadriplegia and was unable to perform any activity of daily living.  The insurer provided final adverse determination denial notice stating, "your current hours can meet your current needs and your request is denied because it is not medically necessary".

The health plan's determination is overturned in whole.

Yes, the increased personal care aide services to 7 days x (2) 12 hour split shifts is medically necessary for this patient.

The patient has the diagnosis of post-polio syndrome with paraplegia but with worsening clinical status now functional quadriplegia, who is unable to perform activities of daily living (ADLs).  Her PCP supported the patient's need for the (2) 12 hour split shifts.  The patient requires 24-hour personal care aide services, and, therefore, the universal assessment tool is not used to assess service hours; however, the most recent assessment tool underestimated the patient's care needs.  Although the overnight logs indicate the patient had confusion and was calling out, her functional quadriplegia necessitates overnight personal care aide services to help the patient with overnight ADL's.  The patient's PCP and the assessment tool indicated that the patient needed turning and repositioning every 2-3 hours not allowing a live-in personal care aide five hours of uninterrupted sleep.  The patient does not have an informal helper.  The requested increase in hours is medically necessary for this patient.