Diagnosis: Chronic obstructive pulmonary disease (COPD).
Treatment: Personal Care Services.

The insurer denied Increase in Personal Care Services (24 Hours per Day, 7 Days per Week). The health plan's determination is overturned.

The patient is a female with a past medical history of chronic obstructive pulmonary disease (COPD), breast cancer, hypothyroidism, osteoarthritis, urinary incontinence, and recent right hip fracture, who had been previously assigned personal care assistant (PCA) services 6 hours/day, 7 days/week to total 42 hours/week. The patient had a fall when unattended with resultant right hip fracture requiring hospitalization and subsequent rehabilitation stay. The occupational therapy (OT) summary of care stated the patient was contact guard assistance with the tasks of toileting, toilet and commode transfers, and bed mobility while noted to need minimum assist with dressing lower body. The discharge assessment by OT also noted the patient to require set up help with hygiene and grooming and supervision with dressing upper body.

The Increase in Personal Care Services: 24 Hours per Day, 7 Days per Week is medically necessary.

The patient had a documented change in functional status following a fall with right hip fracture. The patient required help with all ADLs and Instrumental activities of daily living (IADLs) except eating. The patient's occupational and physical therapy notes from the discharge from rehabilitation indicated the patient needed some assistance with toileting, toilet and commode transfer, bed mobility, dressing, ambulation, and transfers. The patient's orthopedic provider and PCP (primary care physician) indicated the patient needed assistance with ADLs 24 hours/day. The patient has unscheduled and unpredictable care needs over a particular span of time, which the plan did not take into account. The patient requires assistance with these unscheduled and unpredictable care needs including, but not limited to, locomotion, walking, toileting, transfer toilet, and bed mobility. The patient's additional hours are not for safety, supervision or companionship but to assist the patient with safe completion of her ADLs and IADLs. The patient's care needs span 24 hours per day; therefore, the plan should not have utilized the task based assessment tool. The son documents that he and his wife are not able to provide the amount of assistance to meet the patient's care needs, and she therefore does not have informal support outside of the assigned PCA hours. 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.