Diagnosis: Orthopedic/Musculoskeletal
Treatment: Home Health Care

The patient is a female who lives with her son with past medical history of osteoarthritis, hypertension, diabetes mellitus type 2, previous hip fracture with need to ambulate with walker, dementia with hallucinations, depression and urinary incontinence. The patient was assigned Level 2 personal care aide (PCA) services at 8 hours/day, 5 days a week and 7.5 hours/day, 2 days per week base on assessment tool performed on early 2019. There was request for approval of Level 2 PCA services 2-12 hour split shifts/7 days per week to total 168 hours/week. The plan denied this request. There were home visits by primary care physician (PCP) on two occasions indicating the patient's medical history, as documented above. The patient saw a psychiatrist with documentation of above medical diagnoses and notes that patient's son would be moving to Florida. The patient had a Uniform Assessment System - New York Comprehensive Community Assessment Report performed in the spring and again in the end of summer. With task of managing finances and locomotion the patient's level of support worsened from maximal assistance to total assistance. With tasks of personal hygiene and dressing upper extremity/lower extremity (UE/LE) the level of support changed from extensive assistance to maximal assistance. The patient's bed mobility and phone use level of support changed from limited to extensive, while task of eating changed from independent to extensive. In the most recent assessment it was noted the patient had history of altered mental status, hallucinations, increased weakness, dizziness, shortness of breath and poor balance with walking with walker. The patient's son wrote a letter to insurance noting the patient had left the gas on the stove on, allowed water to run over and had fallen when using her walker.

The health plan's determination is upheld.

No, there is no documentation from the PCP or psychiatrist of the patient's overnight needs that would require 2-12 hour split shift personal care aides. There has been a change in status from the first assessment to the time of the assessment with no change in the amount of PCA service hours. The patient had worsening of tasks, as noted above, from the first to the second assessment. In addition, since the most recent assessment there has been a change in the status of the patient's informal helper. The patient's son is moving to Florida, and, therefore, would be unable to continue in caring activities. There should have been an increase in PCA service hours from the first assessment, and the most recent assessment should have noted the patient's informal helper would not be available. (The report indicated she had an informal helper greater than [>] 12 hours per day). The medical records provided support the patient's diagnoses, however, they do not specify the medical necessity for level 2 PCA 12 hrs. per day (split-shift) services.