Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Personal Care Services, 24 Hours per Day, Split Shift (Two 12-Hour Shifts per Day), 7 Days per Week: Total of 168 Hours per Week. The health plan's determination is overturned.

The patient is a female with past medical history of hyperlipidemia, urinary incontinence, hypertension, anxiety, depression, coronary artery disease, gastroesophageal reflux disease (GERD), insomnia, and osteoarthritis who had PCA (personal care assistant) services based on telephonic assessment performed assessing patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, stairs, transportation, equipment management, and bathing. The patient was assessed at limited assistance with tasks of managing medication, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at independent with tasks of bed mobility and eating.

Personal Care Services, 24 Hours per Day, Split Shift (Two 12-Hour Shifts per Day), 7 Days per Week: Total of 168 Hours per Week are medically necessary for this patient.
Per the patient's medical providers and the patient's daughter, the patient has a decline in cognitive and functional abilities since hospitalization. The patient requires assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient has 24-hour care needs and therefore a task based assessment should not be utilized in determining PCA hours. As the patient has not had a recent assessment since her hospitalization it is assumed that she requires split shift services. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The requested increase in PCA services cannot be met solely with adaptive equipment and medical supplies. 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, Personal Care Services, 24 Hours per Day, Split Shift (Two 12-Hour Shifts per Day), 7 Days per Week: Total of 168 Hours per 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.