Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Musculoskeletal/Orthopedic-Osteoarthritis/Hip fracture. 
Treatment: Home Health Care- Personal Care Aide (PCA). 

The plan denied an increase in PCA services: 12 Hours per Day, 7 Days per Week (Split Shift), Total Amount of 168 Hours per Week, as not medically necessary. 

The denial is overturned in whole. 

The patient has a past medical history of hypertension, hyperlipidemia, coronary artery disease, atrial fibrillation, congestive heart failure, history of permanent cardiac pacemaker, bilateral leg edema, gout, hypothyroidism, chronic obstructive pulmonary disease (COPD), memory loss, severe osteoarthritis, frequent falls, fracture, urinary incontinence, magnesium deficiency, lumbar disc degeneration, depression, and hearing loss who had been assigned Personal Care Aide services 6.5 hours/day, 7 days/week to total 45.5 hours/week. The patient had a fall, sustaining a left femoral fracture requiring hospitalization and surgery. The patient had new need for oxygen via nasal canula due to COPD and congestive heart failure. The patient was transferred to inpatient rehabilitation and further rehabilitation at another facility. Occupational therapy and physical therapy noted the patient's weakness with lower extremities, the need for assistance with upper body dressing, lower body dressing, toileting, bathing, bed mobility, transfers, ambulation, and sit to stand. There was a request to increase PCA hours. The patient's primary care physician (PCP) provided a letter outlying the patient's medical diagnoses and further stated the patient is completely dependent on assistance with ambulation, transfer, and toileting. 

The Increase in Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week (Split Shift), Total Amount of 168 Hours per Week is medically necessary for this patient. 
The patient has documented chronic medical conditions with worsening of functional status following the patient's fall with hip fracture. The patient requires assistance with all activities of daily living (ADL's) except phone use. The patient has care needs that are unscheduled and unpredictable, and the patient needs a plan of care that can meet the patient's unscheduled and unpredictable day and nighttime needs. There is documentation of the patient's need for assistance with locomotion, walking, transfer toilet, and toilet use throughout the overnight hours prior to arrival of the current PCA. Following the patient's hospitalization and lengthy rehabilitation stays the patient was placed oxygen via nasal canula further impeding her ability to perform ADLs and Instrumental activities of daily living (IADL's) independently. Because the patient's unscheduled and unpredictable care needs span 24 hours/day, and the patient's living accommodations are not able to provide sleeping arrangements for an overnight aide, split-shift services are medically necessary. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Based on the plan's clinical standards, information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines an increase in PCA hours to 12 hours, split-shift, 7 days/week, to total 168 hours/week is medically necessary. 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.