Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Home Health Care
The insurer denied an increase in personal care services.
The denial was overturned.

The patient is a female with a past medical history of macular degeneration, hearing loss, dementia, depression, panic disorder, bipolar disorder, degenerative disease of the lumbar spine with radiculopathy, and Meniere's disease who had been assigned Personal Care Assistance (PCA) services 12 hours per day, 7 days per week, to total 84 hours per week. There was a request to increase PCA services and the patient underwent telephonic assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, equipment management, locomotion, and transferring to the toilet, while maximum assistance with tasks of managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, and toilet use. The patient was assessed at extensive assistance with tasks of bed mobility and eating. The patient resides alone, has toileting needs 3 times per night, and recently had a medication change from Zyprexa to Seroquel because of her insomnia.

The plan sent a final adverse determination denial, stating increased PCA services were not medically necessary. The denial letter stated the patient continued to need help with preparing meals, housekeeping, laundry, shopping, dressing, bathing, toileting, personal hygiene and moving about while in bed and with eating. In addition, the denial letter stated the patient often loses control of bladder and bowels and the patient wears pull ups to keep herself dry. The insurer noted the patient has a hospital bed to help with position changes and the patient has a Hoyer lift. The plan recommended a pressure reducing mattress and limiting fluids in the evening. 

The patient's medical provider sent a statement of medical necessity for an increase in PCA hours. The provider documented the patient's right femur fracture has contributed to her immobility and hence current wheelchair and bedbound status. The letter stated the patient can no longer independently perform activities of daily living (ADLs) and needs escort to doctor appointments. The letter noted the patient required human assistance in her bed and wheelchair with movement, to serve as fall prevention and bi-hourly turning and positioning to prevent the development of pressure ulcers. 

At issue is the medical necessity for an Increase in Personal Care Services - 24 hours a day, 7 days a week, split shift.

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

Yes, the requested health service/treatment of Increase in Personal Care Services - 24 hours a day, 7 days a week, split shift, is medically necessary for this patient.

There is documentation of decline in physical and mental functioning following a right leg fracture. The universal assessment tool noted the patient requires assistance with all ADLs/Instrumental activities of daily living (IADLs). There is documentation of toileting needs 3 times per night as well as her medical provider recommending bi-hourly positioning. The patient is not able to do them independently. The increase in hours is not solely for safety and supervision, but to assist the patient with safe completion of ADLs. The patient's care needs cannot be met with equipment and medical supplies alone. The patient has unpredictable and unscheduled care needs as well in the daytime and overnight hours. Taking into account the plan's clinical standards, 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, 7 days/week, 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.

Therefore, the requested service of an Increase in Personal Care Services - 24 hours a day, 7 days a week, split shift, is medically necessary for this patient.