Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall Risk
Treatment: Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift)
The insurer denied Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift).
The determination is overturned.

This is a female patient with a medical history notable for dementia. The patient was approved for 35 hours per week of level 2 personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week) and this request was partially denied by the health plan; they did approve an increase to 44 hours per week.
A letter of medical necessity for this appeal was provided by the patient's physician. The letter states that the patient's assessment was incorrect in stating that she is self-directing, because she is not. She is incontinent of bowel and bladder and needs help with transfers. She is frail with a history of multiple falls. She has no informal support in the house. The physician attests that she needs "24 hour / 7 day a week home attendant to assist with her daily needs."
A letter of support for this appeal was provided by the patient's daughter. The letter describes a fall that the patient had while trying to get out of bed. She was taken to the hospital and given rehabilitation. Since that time, she has lost her ability to walk. She "cannot do anything for herself at this point." She wears diapers and requires changing every 2-3 hours due to incontinence. She cannot sit in the same place for more than 2 hours and needs assistance with position changes.
A letter of support for this appeal was provided by the patient's neurologist. The letter states that it is medically necessary for the patient to have assistance with toileting, walking, eating, and medications. The physician recommends care throughout the night as well.
Overnight care logs were provided by the patient's care aide. The logs show that the patient requires assistance every 2-4 hours overnight, generally for toileting and soiled diapers.
A Uniform Assessment System (UAS) was completed and was available for review. Cognition was moderately impaired; the patient was alert and oriented to person only, and confused/disoriented much of the time. From a functional standpoint, she required total dependence for nearly all Instrumental activities of daily living (IADLs) 's. For her activities of daily living (ADLs), she required maximal assistance for bathing, dressing lower body, walking, and locomotion. She required extensive assistance for hygiene, dressing upper body, toilet transfer, and toilet use. She was independent with bed mobility. She is frequently incontinent of urine and stool. Pull ups require changing 5-6 times per day (and throughout the night). At issue is the medical necessity of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift).

The requested health service/treatment of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is medically necessary for this patient.
The documentation clearly demonstrates that the patient has personal care needs which are continuous throughout the day and night. She has incontinence of urine and stool and requires diaper changes that will occur at unpredictable and unscheduled times. Furthermore, she seems to have had a functional decline since her fall. Although a new Uniform Assessment System (UAS) has not yet been completed, she now seems to be non-ambulatory and completely dependent on others. She will likely require turning and repositioning throughout the day and night as well. She cannot be left alone without providing for her functional needs. Her fall is evidence that she cannot perform personal care tasks independently. It is medically necessary for her to have 24 hour split-shift care to address her toileting, positioning, and other personal care needs. Failure to provide for these needs could result in skin breakdown and/or infection.