Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral chronic knee pain, spondylolisthesis of multiple sites in spine
Treatment: Personal Care Services, 24 hours a day, 7 days a week (split shift)
The insurer denied the Personal Care Services, 24 hours a day, 7 days a week (split shift).
The health plan's determination is overturned.

The patient is a female with a past medical history of hyperlipidemia, hypertension, osteoporosis, osteoarthritis, bilateral chronic knee pain, spondylolisthesis of multiple sites in the spine and lumbar disc disease. She also has a medical history of pseudogout, glaucoma, cobalamin (Vitamin B12) deficiency, hearing loss and urinary incontinence who had been assigned personal care assistant (PCA) services 10 hours per day, 7 days per week, to total 70 hours per week. The patient had a fall with subsequent hospitalization for a right shoulder fracture. The patient's medical provider sent a letter stating the patient required total care due to her new injury and fracture and requested services 24 hours per day, 7 days per week, to total 168 hours of care per week to allow the patient to receive the assistance that she needs with her daily care needs. The patient's orthopedic provider sent a letter stating that the patient was unable to care for herself as per physical and occupational therapy. The letter also stated the patient ambulated with assistive devices however she is unable to use these because she cannot weight-bear secondary to her right humeral fracture. In addition, the provider stated it was their medical opinion that the patient needed 24 hour care for the next 6 weeks and there was no concern for altered mental status.

The patient was discharged to home. The patient underwent a video assessment assessing the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, dressing lower body, walking, locomotion, transferring to the toilet and toilet use. With tasks of managing medication, personal hygiene, and dressing upper body the patient was assessed at extensive assistance while limited assistance was needed with the tasks of phone use, bed mobility, and eating. Notes from the assessment stated the patient's daughters had been staying with her overnight after PCA services since the patient had her fall and they are not able to do this any longer as they both work full-time and have family's to care for. The plan recommended the patient split her current hours into 2 shifts to better meet her morning and evening needs.

There is documentation of medical necessity of increased PCA services both from her primary care physician (or provider) (PCP) and her orthopedic provider. There is documentation that the patient is up 3 to 4 times overnight to urinate. The plan's assessment noted the patient requires at least extensive assistance with transfers to the toilet and toilet use. The patient therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. With assistance needs with ambulation and transfer toilet and toilet use in the overnight hours 3 to 4 times at night, a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The requested increase in PCA services cannot be met solely with adaptive equipment and medical supplies. 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.