Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Home Health Care.
The insurer denied personal care services 8-12 hours per day x 7 days a week.
The denial is overturned.

The patient is a female with past medical history of hypertension, gastroesophageal reflux disease (GERD), anxiety, and urinary incontinence who had been assigned Personal Care Assistance (PCA) services 27 hours per week. The patient had a fall with fourth lumbar vertebral fracture with five day hospitalization and transfer to Skilled Nursing Facility (SNF).
The plan sent initial adverse determination denial notice approving 31 hours/week. The plan noted the patient would provide incontinence supplies and personal care services shall not be authorized if a patient's needs can be met by equipment or supplies. In addition, the denial stated the plan does not provide and aide for companionship when tasks are not being done. The plan recommended physical therapy (PT). The patient's daughter sent a note via fax stating the patient is not able to prepare food for herself due to her conditions, is extremely afraid of falling, is not able to see from one eye, is recovering from a fall she had, and she has chronic pain from her fall with lumbar fracture.

The subject under review is the medical necessity for the personal care services 8-12 hours a day x 7 days a week.

The health plan's determination is overturned.

Yes, the requested treatment of personal care service 8-12 hours x 7 days a week is medically necessary for this patient. The patient had functional decline following her fall with lumbar fracture. She was in rehabilitation and their interdisciplinary team recommended an increase in PCA hours to at least 8 hours/day, 7 days/week. The patient has unscheduled and unpredictable care needs over a continuum of time. The patient's care needs cannot be met with medical supplies and adaptive equipment alone. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs)/Instrumental activities of daily living (IADLs). The patient is not able to ambulate or walk without the assistance of another person. 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 8-12 hours/day, 7 days/week, to total 56-84 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.