Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip fracture
Treatment is level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift)
The insurer denied coverage for level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift)
The denial is overturned

This patient has substantial functional impairment associated with various medical conditions, including recent hip fracture, s/p (status post) surgery. The patient's son reported that the patient lives alone in the upstairs apartment of a two-family home and her other son lives downstairs. Some informal help is provided by the son who lives downstairs, but the patient depends primarily on personal care services (PCS) for assistance with most daily activities. She had been receiving PCS 70 hours per week. The patient (via designee) requested an increase of PCS to 24 hours per day (split shift), which was denied; but the insurer approved 24 hours per day live-in services. An external appeal was requested for PCS 24 hours per day (split shift).

The most recent UAS was reviewed. The patient's functional status report for instrumental activities of daily living (IADLs) indicates the patient is totally dependent for meal preparation, ordinary housework, shopping; she needs maximal assistance for managing finances, stairs, transportation; extensive assistance for managing medications, and phone use. For activities of daily living (ADLs), the patient needs maximal assistance for bathing, dressing her lower body, walking, locomotion, transfer toilet, toilet use; extensive assistance for dressing her upper body; setup help for personal hygiene, eating; and is independent for bed mobility. 

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple chronic medical conditions resulting in physical and/or cognitive impairment. Other factors include economic and social circumstances, (e.g., caregiver support). The information provided for review indicates the patient recently fractured her left hip due to a fall which required surgery and then she was transferred to a facility for short term rehabilitation. There are no records available for review from the hospital or rehab facility. Her functional status at the time of discharge from the rehab facility is not known. The UAS indicated the patient needed substantial assistance for most IADLs and ADLs. 

The information provided for review indicates the patient has substantial functional impairment requiring high level of assistance with most ADLs and IADLs. Without adequate and timely assistance for daily activities, the patient is at high risk for adverse health and safety events e.g., skin damage due to inadequate incontinence care; pressure injury; falls; and inadequate pain control. Therefore, it is medically necessary to have a caregiver present and awake who can provide care through the day and night. This includes routine IADLs (meal preparation/service, household related tasks); routine morning and evening ADLs; assist/supervise with eating as needed; plus, ADLs that occur at unscheduled and recurring times of the day and night, including frequent toileting/incontinence care; repositioning for pressure relief on a regular basis, for pain relief when needed; and out of bed mobility when needed. There are no nighttime activity logs provided for review, but considering these day and nighttime care needs, there does not appear to be a clear and consistent opportunity for a live-in aide to have 5 uninterrupted hours of sleep daily on a regular basis.

Recommendation is given to approve Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, 24 hours per day (split shift).

The insurer's denial of coverage for level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is overturned. Medical Necessity is substantiated.