Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis/Rheumatoid Arthritis. 
Treatment: Personal Care Assistance (PCA) Services. 

The insurer denied Personal Care Assistance (PCA) Services: 24 Hours per Day, 7 Days per Week (Split Shift). The health plan's determination is overturned. 

The patient is a female with past medical history of osteoarthritis, rheumatoid arthritis, chronic kidney disease, congestive heart failure, permanent pacemaker, urinary incontinence, obesity, hypertension, hyperlipidemia, anemia, gout, peripheral neuropathy, chronic lymphedema, and diabetes mellitus (DM) type 2 who had a reverse shoulder replacement with a complicated hospital course due to sepsis and was then transferred to rehabilitation facility. The patient's rehabilitation course was complicated by rheumatoid arthritis flare, urinary tract infection (UTI), dyspnea and lightheadedness. The patient underwent telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, bathing, and locomotion while maximum assistance with tasks of managing medication, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use. The patient was assessed at extensive assistance with tasks of managing finances, phone use, transportation, bed mobility, and eating. Notes from this assessment stated the patient was wheelchair bound or using a scooter, was unable to use left arm, had increased right arm pain due to compensating for left, was unable to cut food, was unable to open pill bottles, had to be wheeled by others, and had no informal help. 

Personal Care Assistance (PCA) Services: 24 Hours per Day, 7 Days per Week (Split Shift) is medically necessary for this patient. The patient has documented progressive musculoskeletal diagnoses of osteoarthritis and rheumatoid arthritis. There is documented functional limitations related to these diagnoses and they have worsened since her left shoulder replacement as she is unable to significantly weight bear on the left and has had increasing right shoulder/arm pain and decreased mobility related to compensating for the left shoulder replacement. The patient requires at least extensive assistance with all activities of daily living (ADL)/Instrumental activities of daily living (IADL) tasks. The patient is incontinent of urine and requires assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time. The patient has 24 hour care needs and the Uniform Assessment System (UAS) should not have been utilized to calculate the patient's PCA hours. The patient's care needs cannot be met by adaptive equipment and supplies alone. The patient has no informal helper. The patient's rheumatologist documented the need for assistance every few hours and the need for strict hygiene regarding her skin from urine and feces. The patient is treated with diuretic therapy with history of congestive heart failure (CHF), increasing urination and her need for assistance with toilet transfer, toilet use, and incontinence care. There was a discrepancy in assistance needs with physical therapy (PT) / occupational therapy (OT) notes from rehabilitation but the PT notes align with the UAS notes. The request to increase PCA hours is not solely for safety and supervision but to assist the patient with safe completion of 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, the requested PCA services 24 hours/day, split-shift, 7days/week are medically necessary for this patient.