Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/musculoskeletal.
Treatment: Home health care.
The insurer denied the medical necessity of an increase in PCA services.
The health plan determination is overturned in whole.

The patient has a past medical history of hypertension, gastroesophageal reflux disease (GERD) , osteoarthritis, weakness, abnormality of gait and chronic fatigue who had been assigned 8 hours/week of CDPAS services based on a telephonic assessment tool. The day after the assessment tool the patient was taken to the hospital with altered mental status and was found to have urinary tract infection (UTI) and osteomyelitis of the frontal sinus. The patient required surgery, consultation with plastic surgery, infectious disease and ear, nose, and throat (ENT) and was treated with intravenous (IV) cefazolin and oral flagyl. The patient was treated with anti-seizure medication. The patient was transferred to rehabilitation and planned to discharge to home pending safe discharge plan. The patient had another telephonic assessment tool performed on and was felt to need total assistance with task of ordinary housework, maximum assistance with tasks of meal preparation, managing finances, managing medication and shopping, extensive assistance with tasks of phone use, stairs, transportation and bathing, limited assistance with tasks of personal hygiene, dressing upper/lower body, transfer toilet and toilet use, supervision with task of eating and independent with bed mobility. The patient's provider requested 70 hours/week of PCA services (not CDPAS) The patient was assigned 38 hours/week. While in rehabilitation the patient had episodes of delirium and confusion. The patient frequently refused medication including IV medication to treat osteomyelitis. The patient was seen by psychiatry and initially felt to have capacity to make decisions but with the ongoing delirium, later in the rehabilitation stay the patient was deemed not capable of making own decisions. The recommendation from rehabilitation providers was to have PCA services 8-12 hours/day. Physical therapy (PT) and occupational therapy (OT) noted the patient to need stand by help with bathing, dressing lower body, walking, locomotion, toilet use and bed mobility and independent with personal hygiene and dressing upper body. 

The patient would not need PCA services for safety and supervision alone, but to assist with activities of daily living (ADL) tasks that would occur on an unscheduled basis (walking and moving around the home to use the bathroom). The patient would require PCA services when there was not an informal helper present. The tasking tool from post hospitalization indicated the patient would need help 15 minutes per day with locomotion and 15 minutes per day with transferring, although this would be estimated to be much more as the patient was not independent with walking, locomotion, and bed mobility. The telephonic assessment nurse did not communicate with the patient's care team (OT/PT) who would have known the specific level of help the patient needed with tasks, following a prolonged hospitalization and rehabilitation stay in the setting of debilitation and delirium. The patient was deemed not capable of making  own decisions by psychiatry. The recommendation from rehabilitation providers was to have PCA services 8-12 hours/day. Physical therapy and occupational therapy noted the patient to need stand by help with bathing, dressing lower body, walking, locomotion, toilet use and bed mobility.