Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, Parkinson's disease, glaucoma. 
Treatment: Personal Care Services (PCS) - 24 Hours a day, 7 Days a week- (Split-Shift) for a total of 168 hours. 
The insurer denied: Personal Care Services (PCS) - 24 Hours a day, 7 Days a week- (Split-Shift) for a total of 168 hours.  
The denial is overturned. 

This elderly female patient has medical conditions that include heart failure, Parkinson's disease, glaucoma, cognitive decline, hypertension, and chronic pain. The denial of an increase in personal care services (24 hours a day, 7 days a week [split shift] for a total of 168 hours) is being appealed. The health plan approved 24 hours a day, 7 days a week (live-in), total of 91 hours. Uniform Assessment System (UAS) evaluation completed 5 months ago shows maximal assistance to total dependence with activities of daily living (ADLs), except extensive assistance with managing medications. The patient is wheelchair bound. She has bowel and bladder incontinence. An appeal from New York State reports this patient has multiple chronic conditions and needs assistance with activities of daily living. She needs overnight assistance per a provider who reports she is bedbound and unable to turn or reposition herself. She has incontinence. Her primary mode of locomotion is a wheelchair. Night logs show assistance every two hours with repositioning. 

The requested health service 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 (ADLs), including toileting, walking, transfers, 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. This patient has multiple chronic conditions and is bed and wheelchair bound. The denial of an increase in personal care services (24 hours a day, seven days a week [split shift] for a total of 168 hours) is being appealed. The health plan approved 24 hours a day, seven days a week (live-in), total of 91 hours. Uniform Assessment System (UAS) evaluation completed 5 months ago shows the patient requires maximal assistance to total dependence with activities of daily living, except extensive assistance with managing medications. She has bowel and bladder incontinence. The appeal statements indicate nighttime assistance is needed for assistance with activities of daily living. This is supported by night logs showing repositioning every two hours. This patient has continuous needs, including frequent turning/repositioning that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved live-in personal care services are insufficient to meet the patient's needs for assistance with activities of daily living and personal care. The proposed personal care services 24 hours a day, seven days a week (split shift), for a total of 168 hours is indicated.