Diagnosis: Coronary Artery Disease (CAD), Diabetes and congestive heart failure (CHF)

Treatment: Personal care assistant (PCA) services of 7 days times 24 hours (split shift)

The insurer denied coverage for personal care assistant (PCA) services of 7 days times 24 hours (split shift)

The denial is overturned.

This case involves an elderly female with a history of coronary artery disease status post 3 stents, angina, congestive heart failure, hypertension, peripheral vascular disease, diabetes, arthritis, prior hip fracture in addition to a fall resulting in an additional fracture to the right ulna. It is noted she is wheelchair-bound. The documentation indicated she has been amended for increased home care hours to 12 hours a day due to her being totally dependent on others. The documentation does include discharge summary where it was noted her indication for admission was due to a fall causing a nondisplaced right hip fracture. The documentation does indicate she is insulin-dependent. The patient was consulted by orthopedics where she was placed in a right upper extremity posterior splint and was recommended to be weightbearing as tolerated to the right lower extremity. She did not undergo surgical intervention. She was offered rehabilitation; however, the family refused and requested the patient be discharged. She was discharged with a wheelchair in addition to pull-ups and a commode and was given oxycodone in addition to Tylenol.

The patient has multiple medical issues including coronary artery disease (CAD), diabetes and congestive heart failure (CHF). She has sustained three falls which resulted in a fracture every single time. She is said to be wheelchair bound and dependent on others for all her activities of daily living (ADL).

Based on the provided information this lady has been declining and is at extremely high risk for adverse events due to her high fall risk from increased frailty and debility. She is also at higher risk for hospitalization due to her underlying comorbidities. She is appropriate to receive the requested PCA services of 7 days x 24 hours (split shift) due to all the reasons mentioned.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the requested Personal Care Assistant (PCA) Services of 7 days times 24 hours (split shift) is substantiated. The insurer's denial is overturned.