Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Hip fracture. 
Treatment: Personal care services, 24 hours a day, 7 days a week (split-shift) for a total of 168 hours. 

The insurer denied personal care services, 24 hours a day, 7 days a week (split-shift) for a total of 168 hours. 

The determination is overturned. 

The patient has a past medical history of dementia, hypertension, osteoarthritis, coronavirus (COVID)-19 infection, congestive heart failure, Alzheimer's dementia, insomnia, anxiety, gastroesophageal reflux disease (GERD), bladder incontinence, and bowel incontinence who had been assigned personal care assistant (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week. 

The patient was admitted to the hospital following a fall and was diagnosed with a hip fracture. The patient underwent right hip open reduction internal fixation (ORIF). The patient was transferred to rehabilitation. There was a request to increase PCA services with a letter from the rehabilitation physician stating prior to admission the patient had been living alone in an apartment and had been receiving PCA services 12 hours/day, 7 days/week, however, since that time the patient had a significant decline in her medical, functional, and cognitive status and now required extensive assistance for all activities of daily living (ADLs). The letter also stated the patient required to be turned and repositioned on an hourly basis in order to prevent skin breakdown and pressure ulcers which she was at risk of getting due to her total dependency on ADLs. In addition, the rehabilitation facility's medical provider stated the patient was having increased periods of confusion throughout the day and night as well as frequent episodes of anxiety and confusion with difficulty sleeping through the night. The provider strongly recommended the patient to have PCA services 24 hours/day in split shift, 7 days/week to return and remain safe in the community. The letter also stated it was unlikely that an attendant would be able to get any consecutive hours of uninterrupted sleep as the patient required to be turned and positioned at least every 2 hours in order to prevent skin breakdown and bedsores and also due to her increased confusion and agitation at night.
The patient underwent a telephonic assessment assessing the patient at total assistance with the tasks of ordinary housework, stairs, dressing lower body, and locomotion while maximum assistance with tasks of meal preparation, managing finances, managing medication, shopping, transportation, bathing, transfer toilet, and toilet use. With the tasks of phone use, personal hygiene, dressing upper body, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. The activity of walking did not occur and the assessment also noted the patient had no informal help. 
The insurer sent an initial adverse determination denial notice denying the request to increase PCA services. The insurer sent a final adverse determination denial notice denying request to increase PCA services stating they reviewed the assessment, daughter's appeal statement, care management record, and the provider letter from rehabilitation in making their decision. The denial stated an aide could not always be with the patient while they were in her home and could not prevent the patient from falls or injuries. The denial letter also recommended patient continue in-home physical therapy upon discharge as well as in-home occupational therapy to help modify her daily activities. In addition, the denial letter stated the patient was provided incontinence products to help keep the patient dry and recommended a bedside commode to help limit the number of times the patient needed to get up to go to the bathroom. The insurer recommended a hospital bed to help with turning while in bed and a pressure relieving mattress to help reduce pressure from areas of the patient's body while in bed. The denial letter also stated they recommended the patient speak to a care coordinator to review the patient's current needs and living conditions and recommended the most suitable and safe setting for the patient. Lastly, the plan recommended the patient split her approved aide schedule into 2 shifts to better meet her morning and evening needs. The patient's healthcare advocate provided a request for an external appeal of denial decision by insurer to cover PCA services 24 hours/day, split shift, 7 days/week.
At issue is the medical necessity of personal care services, 24 hours a day, 7 days a week (split-shift) for a total of 168 hours. 
The services are medically necessary. 
The patient has documented worsening physical and cognitive functioning following a fall with a fracture resulting in rehabilitation stay. The patient's medical provider has documented the medical necessity of 24-hour services, specifically noting that the patient requires turning and repositioning every 1-2 hours. The assessment noted the patient needed extensive assistance with bed mobility such that a hospital bed would not provide the needed support for the patient to turn and reposition on her own. The patient requires maximum assistance with transfer toilet and toilet use which are unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. As the patient has 24-hour care needs, the plan should not have used the assessment tool in calculating PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's overnight care needs would not allow a live-in aide the ability to obtain five hours of uninterrupted sleep. The patient has no informal help. 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, 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.