Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied Personal Care Services, Level 2-24 hours per day, 7 days per week (live in). 
The denial was overturned in part. 

The patient is a female with a past medical history significant for hypertension, hyperlipidemia, osteoarthritis, osteoporosis, dizziness, varicose veins, bilateral lower extremity edema, muscle weakness, gait and balance abnormalities, insomnia, fatigue, chronic pain in legs, depression, panic attacks, urinary frequency, urinary incontinence, bowel incontinence, confusion, age-related cognitive decline along with recent fall and fracture of left humerus.
Services were denied by her health plan stating the following, "We have approved 4 hours per day times () 5 days a week and 5 hours per day 2 days a week for a total of 30-hour week of services. You need extensive assistance with bathing, personal hygiene, dressing upper body, dressing lower body, walking, toilet transfer and toilet use. She requires set up with bed mobility and eating. Therefore, we will partially improve and increasing personal care assistant hours to 42 hours per week. This is based upon the most recent assessment. Patient has no overnight needs."
An appeal letter from provider requested additional assistance secondary to urinary incontinence, decreased ability to function independently secondary to recent fracture of the shoulder, gait, and balance issues. Physicians note requested additional assistance. 
Services were denied based upon medical necessity. The patient is appealing the decision.
At issue is the medical necessity of Personal Care Services, Level 2-24 hours per day, 7 days per week (live in). 

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

The requested health service/treatment of Personal Care Services, Level 2-24 hours per day, 7 days per week (live in) is medically necessary for this patient in part.
The patient is a female with multiple medical problems who fell several months ago resulting in a fracture of the left humerus which affected her independence along with requiring more services for activities of daily living (ADL)s, specifically with toilet transfer and use. The patient requires additional services temporarily until her fracture has healed. Recommend an increase in services to 10 hours per day times () 7 days a week.
Recommending an increase in the amount of services to 10 hours per day 7 days a week until the patient's medical situation can be reassessed. The patient has no specific nighttime needs necessitating live-in services. The patient does have a functional decrease in activities of daily living (ADL)s as noted through the 2 assessments. This is secondary to the recent shoulder fracture limiting her ability to ambulate with a walker, transferring to the bathroom and using a toilet with limited assistance. The other ADLs that were assessed did not show significant changes in her ability to function. The patient was independent prior to this. The only change in her medical status was a fall resulting in fracture of her left humerus. This will be temporary while she has recovery from her shoulder injury. There does not appear to be any other specific medical conditions with changes in the recent past which necessitated a change in amount of medically necessary services otherwise.
Therefore, the requested health service/treatment of Personal Care Services, Level 2-24 hours per day, 7 days per week (live in) is medically necessary for this patient in part, with an increase in services to 10 hours per day x 7 days a week.