Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal- fracture.
Treatment: Home Health Care.
The insurer denied an increase in Personal Care Services to 84 hours per week. 
The denial was overturned in whole.

The patient is a female with a past medical history of oxygen dependent chronic obstructive pulmonary disease (COPD), hypertension, morbid obesity, lymphedema, coronary artery disease, congestive heart failure, osteoarthritis, urinary incontinence, breast cancer, and peripheral neuropathy. The patient had a fall with resultant left femur fracture. The patient underwent a left open reduction internal fixation (ORIF) and knee revision with subsequent transfer to rehabilitation. Occupational Therapy  stated the patient could bed roll to the left using bed rail with minimal assistance, could move from supine to sit using bed rail with supervision, required maximum assistance to don and doff pants, required substantial/maximum assistance for toilet transfer, was independent with eating, was dependent on toileting hygiene, showering, and bathing, and was moderate assistance with upper body dressing and maximum assistance with lower body dressing. Physical therapy stated the patient was able to ambulate with a rollator walker with contact-guard and supervision and required increased time to complete mobility tasks.
The rehabilitation physician provided a letter recommending a home health aide for 24 hours a day, 7 days/week as she required assistance with all activities of daily living (ADL)s including ambulation, transferring, toileting, upper and lower body dressing, and bathing. The patient underwent a telephonic assessment tool assessing the patient at total assistance with tasks of ordinary housework while maximum assistance with tasks of meal preparation, shopping, bathing, dressing lower body, walking, and locomotion. The patient was assessed at extensive assistance with tasks of managing medication, transportation, dressing upper body, transfer toilet, toilet use, and bed mobility while limited assistance with tasks of managing finances, equipment management, and personal hygiene. With the task of eating the patient was assessed at independent and set up help only for phone use.
The insurer sent a final adverse determination denial notice denying request to increase PCA services. 
At issue is the medical necessity of an increase in Personal Care Services 12 hours (hrs) times (x) 7 days per week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of increase in Personal Care Services 12 hrs x 7 days per week is medically necessary for this patient.
The patient has documented chronic medical conditions of oxygen dependent COPD, osteoarthritis, urinary incontinence, and a functional decline following a fall. The patient requires assistance with all ADLs except for eating and bed mobility. The telephonic assessment tool  appears to have underestimated the patient's assistant's needs with equipment management, personal hygiene, bed mobility and transfer to toilet when compared to the rehabilitation facility's evaluation of the patient's assistance needs. The patient has unpredictable and unscheduled care needs that span a continuum of time. The increase in PCA service hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/Instrumental activities of daily living (IADL)s. 
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.
Therefore, the increase in Personal Care Services(PCA) to 12 hrs x 7 days per week is medically necessary for this patient.