Diagnosis: Osteoarthritis
Treatment: Personal Care Worker (PCW)
The insurer denied Personal Care Worker (PCW) Service: 24-hour split shift. The health plan's determination is overturned.

The Patient is a female with past medical history of hyperlipidemia, depression, bioprosthetic aortic valve, permanent pacemaker, knee osteoarthritis, chronic obstructive pulmonary disease (COPD), and urinary incontinence who had undergone a left total knee replacement with subsequent wound dehiscence and infection. The patient required washout and debridement. There was a request for PCW (personal care worker) services and the patient was assessed at maximum assistance with meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing medication, stairs, transportation, bathing, dressing upper/lower body. The patient was assessed at limited assistance with tasks of managing finances, phone use, equipment management, personal hygiene, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. Notes indicated that the patient was in the process of appeal to increase PCW hours.

Personal Care Worker (PCW) Service: 24-hour split shift is medically necessary for this patient.
The patient has documented need for assistance with all activities of daily living (ADL) and instrumental activities of daily living (IADL). The patient had a complicated course following left knee replacement with subsequent infection and need for prolonged intravenous (IV) antibiotics and subsequent surgery. The patient had a prolonged rehabilitation stay and although she may progress with physical therapy and occupational therapy she continued to require assistance with all ADLs and IADLs. The patient developed a sore on her left heel during her hospitalization and subsequent rehabilitation stay requiring frequent repositioning. The patient is up at night to use the bathroom with needed assistance with ADLs to complete this task at least every 3 hours such that a PCW would not be able to obtain 5 hours of uninterrupted sleep. The increase in PCW hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs. It cannot be assumed that the patient's family can provide formal/informal help during the current hours the patient doesn't have PCW services, which would be up to 16 hours/day. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCW services 24 hours/day, split-shift 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.