Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Joint Problem/Pain.
Treatment: Home Health Care/home care/personal care HHC- Level 2 personal care services, per 15 minutes increase to 24 hours per day (split-shift). 
The health plan denied the requested home care/personal care HHC- Level 2 personal care services, per 15 minutes increase to 24 hours per day (split-shift) as not medically necessary. 
The health plan's determination is upheld.
 
The patient is a female with a past medical history of diabetes mellitus type 2, hypertension, osteoarthritis, bladder incontinence, and lupus. The patient had imaging of her knees with an x-ray showing mild bilateral tricompartmental osteoarthritis and large patellar enthesophytes bilaterally with small bilateral effusions. The patient's medical provider filled out a form (department of health 4359) based on a physical examination stating the patient needed assistance with cooking, cleaning, dressing, showering, medication administration, and physician appointments. The form also stated the patient needed 10 hours of home health aide services. The patient underwent an assessment for personal care assistant (PCA) services, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, shopping, and bathing while maximum assistance with tasks of stairs, transportation, walking, locomotion, transfer toilet, and toilet use. With tasks of managing medication, personal hygiene, dressing upper/lower body, the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating. 

The patient's medical provider sent a letter stating the patient now had 150 hours/week of home care and they were requesting 24 hours/day, 7 days/week, as she had mild to moderate impairment and limited range of motion in the upper and lower extremities which prevented her from doing her activities of daily living (ADLs) and being at risk for more falls. The letter also stated the requested service was medically necessary to avoid undesirable consequences and the patient's health had deteriorated and she had very limited range of motion due to excruciating joint pain. In addition, the letter stated the patient was seeing a neurologist, pain management, and physical therapist and was planning to have a bilateral knee arthroscopy. 

At issue is the medical necessity for the requested home care/personal care HHC- Level 2 personal care services, per 15 minutes increase to 24 hours per day (split-shift).

The health plan's determination of medical necessity is upheld, in whole.

No, the request for PCA services, 24 hours/day, split shift, is not medically necessary for this patient. There is no documentation from the patient's medical provider of a need for turning and repositioning every 2 hours. There is no documentation with overnight care logs supporting the need for split shift services. There is no documentation of overnight care needs with ADLs that would not allow a PCA 5 hours of uninterrupted sleep. 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, split shift are not medically necessary for this patient.