Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip fracture/gait instability
Treatment: Personal Care Services (PCS)
The insurer denied Personal Care Services: 24 Hours per Day, 7 Days per Week (Split Shift) for a Total of 168 Hours per Week.
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, cardiac arrhythmia, osteoarthritis, urinary incontinence, and bowel incontinence who had a fall with a left hip fracture. The patient had a right hip fracture requiring open reduction internal fixation (ORIF) and hospitalization and was transferred to rehabilitation facility. Physical therapy and occupational therapy notes at her end of care noted the patient required set up help with feeding, supervision with grooming, moderate assistance with toileting, dressing lower body, bed mobility, and bathing. In addition, the patient was completely dependent with wheelchair mobility, minimal assistance with sit to stand, moderate assistance with toilet wheelchair and bed to wheelchair. The patient underwent a universal assessment tool, in person, while at rehab, assessing the patient at total assistance with ordinary housework and stairs while maximum assistance with meal preparation, shopping, transportation, bathing, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, and personal hygiene while limited assistance with task of eating. 

Personal Care Services: 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week are medically necessary for this patient. 

There is documentation by the patient's medical provider, physical therapist and occupational therapist that the patient requires at least limited assistance with all activities of daily living (ADLs). She requires maximum assistance with walking and locomotion as well as transfer toilet, toilet use, and bed mobility. The patient also 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. Overnight logs document that the patient requires assistance with personal care at least every 2-1/2 hours overnight which would not allow a personal care aide to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCS is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and/or medical supplies. The patient has a son and daughter who are not available to provide informal support. 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, PCS 24 hours/day, 7 days/week, split-shift, to total 168 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.