Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence/Urinary/Bladder Control
Treatment: Personal Care Service 2- 12 hour shifts, 7 days per week
The health plan denied Personal Care Service 2- 12 hour shifts, 7 days per week.
The determination is Overturned.

The patient is a female with medical history notable for coronary artery disease, dementia, and urinary incontinence. The patient is approved for 24-hour live in personal care services. The patient and her care team requested an increase to 24-hour split-shift (2-12-hour shifts), 7 days per week, and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The physician states that the patient's condition has deteriorated. She is bed-bound and is unable to reposition herself in bed every 2-3 hours throughout the day and night. She has incontinence and requires prompt assistance with changes. Her current level of home care services "are no longer sufficient for her needs" and the physician requests continuous care for the day and night.
The patient's granddaughter provided a letter of support for this appeal. The letter states that the patient has had to be hospitalized three times in the past two months due to multiple falls and a hip fracture. She has newly diagnosed congestive heart failure and associated fluid overload; this leads to frequent toileting needs. She is on oxygen chronically. She developed a pressure ulcer of the left heel and requires turning and repositioning every 2 hours to promote healing.
A Uniform Assessment System (UAS) was available for review. The assessment was conducted in person after the patient's discharge from the hospital the week prior. The patient's cognition is severely impaired; she recognizes close family but little else. She requires total dependence for all instrumental activities of daily living (IADL). She requires total dependence for nearly all activities of daily living (ADL) with the exception of maximal assistance for hygiene and eating. She is frequently incontinent of urine and stool.
Nursing notes were provided for review. The patient's right heel pressure ulcer is stage 2 and had reopened. She continues to receive nursing care. The nursing notes state the patient is at high risk of present wound deterioration and for developing new wounds and pressure ulcers.
The patient's recent hospital visit discharge summaries were provided for this review. The patient was started on guideline directed medical therapy for her new onset of congestive heart failure. She was started on diuretics and oxygen.
At issue is the medical necessity of Personal Care Service 2- 12-hour shifts, 7 days per week.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Personal Care Service 2- 12-hour shifts, 7 days per week is medically necessary for this patient.
The patient has advanced dementia and cannot direct her own care. She requires total dependence for essentially all ADL's (activities of daily living) including toileting and bed mobility. She has a pressure ulcer of the heel that requires turning and repositioning every 2 hours. She has incontinence of urine and stool and requires prompt and frequent diaper changes throughout the day and night. Her care needs are by definition continuous and unscheduled and would be expected to occur throughout all hours of the day. Split-shift care is medically necessary and appropriate for the patient.