Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right ankle fracture
Treatment: Increase in personal care services to 24 hours a day, 7 days a week (split-shift), for a total of 168 hours
The insurer denied an increase in personal care services to 24 hours a day, 7 days a week (split-shift), for a total of 168 hours.
The health plan's determination is overturned.

The patient has a past medical history of congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), hypertension, hypothyroidism, hyperlipidemia, recurrent urinary tract infection (UTI), osteoarthritis, osteoporosis, obesity, gastroesophageal reflux disease (GERD), anxiety and depression, insomnia, and urinary incontinence who had been assigned personal care assistant (PCA) services 11 hours/day, 7 days/week, to total 77 hours/week. The patient had a fall with a resultant right ankle fracture with hospitalization and subsequent transfer to short-term rehabilitation (rehab). The patient was nonweightbearing on her right ankle. The patient was receiving occupational therapy (OT) and physical therapy (PT).

The occupational therapy notes stated the patient required total assistance with lower body dressing, maximum assistance with toileting, maximum assistance with bathing, and maximum assistance with functional mobility during activities of daily living (ADLs). The physical therapy notes stated the patient required moderate assist to stand with bed mobility, maximum assistance with transfers, maximum assistance sit to stand, was able to ambulate 0 feet, and static balance was poor.

The provider at short-term rehab provided a letter stating the patient had been residing alone in an apartment prior to admission and since that time had a significant decline in her functional and medical status and now required extensive assistance of 1 person for all ADLs. The letter further stated the patient required around-the-clock total care with all toileting and diaper changing needs on an hourly basis to prevent a UTI which she has a history of. In addition, the provider letter stated the patient was now nonweightbearing due to her right ankle fracture and was at high risk for falls due to an unsteady gait and required maximum assistance with transferring and ambulation and was ADL dependent. The provider letter also stated the patient was bedbound and could not reposition herself without assistance and had episodes of anxiety and confusion with difficulty sleeping through the night. Lastly, the provider letter stated the patient had completed her rehabilitation service and was ready to discharge to home, however, in light of her current medical and functional status he strongly recommended the patient have PCA services 24-hours times (x) 7 days via split shift in order to safely return and remain in the community. The provider also stated it was unlikely that an attendant would be able to obtain any consecutive hours of uninterrupted sleep as the patient required to be turned and repositioned every few hours in order to prevent skin breakdown and bedsores.

The patient underwent a telephonic assessment tool, assessing the patient at total assistance with ordinary housework and stairs, while maximum assistance with meal preparation, shopping, transportation, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, personal hygiene, dressing upper body, locomotion, transfer toilet, toilet use, bed mobility, and eating while limited assistance with phone use. For the task of walking, it was noted that that activity did not occur. Notes from the telephonic assessment stated the patient's ADL status had declined and overall self-sufficiency had deteriorated. In addition, notes from the telephonic assessment stated the patient had no informal helper.

The insurer sent an initial adverse determination denial notice denying the request to increase PCA services, stating the patient currently was in a skilled nursing facility, had received physical therapy, therapy records indicated the patient needed assistance with bed mobility, the patient needed assistance with transfers, the patient walked 15 feet with her walker and assistance, her standing balance was poor, and her sitting balance was fair. The denial notice also stated the current hours met all the tasks the patient needed assistance with and the plan recommended the patient split her hours to meet her morning and evening needs. In addition, the denial stated the plan had not identified any overnight needs, personal care services were not authorized if the need could be met with equipment or supplies, recommended a hospital bed, and recommended physical therapy.

The insurer sent a final adverse determination denial notice continuing to deny the request to increase the PCA services, stating the request was not medically necessary and the patient did not meet criteria. The denial further stated the patient's daughter had requested an increase in PCA services, stating the patient needed more hours when she returned home because of limited mobility and declining health. The denial further stated the assessment showed the patient needed help with meal preparation, housekeeping, shopping, laundry, bathing, personal hygiene, toileting, with turning and positioning while she was in bed, and with eating. In addition, the denial letter stated the patient was currently in a nursing facility but lived alone in the community, had a supportive daughter who lived out of state and the patient was totally dependent on others for activities of daily living. The denial also noted the patient was not able to put any weight on her right ankle. The plan denial also stated per New York State Department of Health guidelines a medical professional must not recommend the number of hours of services that an individual should be authorized to receive. The denial stated the patient could not care for herself and was being cared for by the staff of her current nursing and rehabilitation facility and aide services do not prevent falls or injuries and cannot monitor medical conditions or behaviors. The denial notice also stated personal care services for companion care or for safety supervision are not a covered service under the benefit plan. Lastly, the denial letter stated the patient's care needs could be met with the patient's current service hours.

At issue is the medical necessity of an increase in personal care services to 24 hours a day, 7 days a week (split-shift), for a total of 168 hours.

The services are medically necessary. The patient had a documented decline in functional status following a fall with a right ankle fracture. The patient required a short-term rehabilitation stay with the physical therapy and occupational therapy notes documenting assistance needs greater than noted on the telephonic assessment. The plan's denial stated the patient was able to ambulate 15 feet, however, records from short-term rehab stated the patient was not able to ambulate at all. The patient had no informal helper. The patient required assistance with all ADLs. The patient had unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The provider from short-term rehab documented the patient was bedbound and could not reposition herself without assistance and required assistance with toileting and incontinent care through the overnight hours. In addition, the provider stated the patient required to be turned and repositioned every few hours in order to prevent skin breakdown and bedsores. The patient's overnight care needs would not allow an aide to obtain at least 5 hours of uninterrupted sleep. The patient's care needs cannot be met with the current PCA services and/or adaptive equipment and/or medical supplies. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of ADLs and instrumental ADLs (IADLs). Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, 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.