Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, breast cancer, meningioma, seizures, obesity, anxiety, chronic pain, weakness hypertension, and atrial 
fibrillation
Treatment: Increase Personal Care Service Level 2 to 24 Hours a Day, 7 Days a Week (split shift)
The insurer denied: Increase Personal Care Service Level 2 to 24 Hours a Day, 7 Days a Week (split shift)
The denial is overturned.

The patient is an elderly female. Her medical conditions that include dementia, breast cancer, meningioma, seizures, obesity, anxiety, chronic pain, weakness hypertension, and atrial 
fibrillation. She lives alone. Denial of increase personal care service level 2 to 24 hours a day, 7 days a week (split shift) is being appealed. The health plan approved Personal Care Services (PCS) 12 hours per day, 7 days per week, total 84 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 2 months ago shows minimally impaired cognition and functional status: requires extensive assistance to total dependence with all activities of daily living (ADLs), except limited assistance with personal hygiene and eating. She spends time in bed or wheelchair. She has frequent bladder incontinence. Her last fall was 31 to 90 days ago. An appeal statement from the patient's provider reports the patient was admitted to rehab 4 months ago. There has been a significant decline in the patient's medical, cognitive, and 
functional status. She is now homebound and requires total assistance with all activities of daily living. She has increased periods of confusion at night. She requires to be turned and positioned at least every two hours to assist in preventing skin breakdown and bedsores. She requires split shift for care and safety measures. An appeal statement reports the patient's condition is rapidly deteriorating. She has progressive dementia. She is bedbound and has reduced mobility. She cannot reposition herself in bed. She requires multiple diaper changes due to incontinence. She needs to be repositioned bi-hourly.

The Increase Personal Care Service Level 2 to 24 Hours a Day, 7 Days a Week (split shift) is medically necessary.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, 
walking, transferring, turning/positioning, or feeding. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual who needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase personal care service level 2 to 24 hours a day, 7 days a week (split shift) is being appealed. The health plan approved personal care service 12 hours per day, 7 days per week, total 84 hours per week. This patient has multiple chronic conditions, including recent skilled nursing facility stay for rehab 4 months ago. Uniform Assessment System (UAS) evaluation completed 2 months ago shows she has a minimally impaired cognition and functional status that requires extensive assistance to total dependence with all activities of daily living, except limited assistance with personal hygiene and eating. She is incontinent of bladder. The appeal notes the patient needs assistance with all activities of daily living. She is bedbound. The appeal statements indicate the patient needs continuous care to include frequent turning and repositioning. Per the information provided, this patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested increase in personal care service level 2 to 24 hours a day, 7 days a week (split shift) is medically necessary.