Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Home Health Care.
The insurer denied increase in personal care assistance to 84 hours per week.
The denial is overturned.

The patient is a female with past medical history of osteoporosis, dementia, osteoarthritis, urinary incontinence, constipation, peripheral edema, peripheral vascular disease, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, generalized anxiety disorder, depression, and hypothyroidism who had been assigned personal care assistance (PCA) services 8 hours/day, 7 days/week, to total 56 hours/week. There was a request to increase PCA services and the patient underwent a telephonic assessment tool assessing the patient at extensive assistance with meal preparation, ordinary housework, stairs, shopping, transportation, bathing, personal hygiene, and dressing upper/lower body while limited assistance with tasks of managing finances, managing medication, equipment management, walking, locomotion, transfer toilet, toilet use, and bed mobility. Notes from this assessment stated the patient lived alone, had no informal helper, had a fall with fractured right shoulder, had unsteady gait, was unable to stand for long periods of time, was unable to bend over, was unable to carry heavy objects, was unable to raise hands overhead, was unable to navigate stairs, had a decline in function since fall due to fractured right shoulder, and required assistance to reheat meals. The subject under review is the medical necessity for the increase in hours.

The health plan's determination is overturned.

The requested service of personal care assistance 84 hours per week is medically necessary for this patient. The patient has progressive medical conditions of osteoarthritis and dementia. The patient had a decline in her physical functioning following a fall with right shoulder fracture and documented decline in cognitive function by her psychiatrist. The patient is incontinent of urine. The patient requires at least supervision with all ADL/ Instrumental activities of daily living (IADL) tasks except phone use. The patient has no informal helper. The patient has unscheduled and unpredictable care needs that span a continuum of time. The patient needs assistance with meal preparation (not able to reheat her own meals), medication administration, walking, locomotion, transfer toilet, toilet use, incontinence cares, and personal hygiene outside of the currently assigned PCA hours. An increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7days/week, to total 84 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.