Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, incontinence, HTN (hypertension), COPD (chronic obstructive pulmonary disease), DM (diabetes mellitus), and status post humeral fracture.
Treatment: Increase personal care worker (PCW) Services to 12 hours x 2 (split-shift).
The insurer denied the Increase PCW Services to 12 hours x 2 (split-shift).
The denial is overturned. 

The patient is a male with conditions including Parkinson's disease, incontinence, HTN (hypertension), COPD (chronic obstructive pulmonary disease), DM (diabetes mellitus), and status post humeral fracture.  He has limited ROM (range of motion) of his dominant arm and poor gait due to Parkinson's.  He lives alone and does not have informal support.  He is appealing denial of increase from 24 hour live-in to 24 hour, split-shift PCW (personal care worker) services.

UAS (Uniform Assessment System) evaluation performed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, and transportation; maximal assistance with managing medications, phone use, bathing, personal hygiene, dressing, and toileting; and extensive assistance with walking, locomotion, bed mobility and eating.  He is frequently incontinent of bowel and bladder.

An appeal statement notes the patient is falling often. He was hospitalized with COVID and has residual leg edema, dyspnea and fatigue.  The appeal notes the patient needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation.

A letter from the patient's provider indicates the patient needs an aide to assist with ambulation, toileting, transferring, and turning/repositioning at unscheduled times during the day and night that would prohibit an aide from sleeping five hours consecutively.

Logs have been included showing up to five hours between repositioning, toileting, and transferring throughout the day and night.

Yes, the Increase in personal care worker services to 12 hours x 2 (split-shift) is medically necessary.
Medically necessary services are those which are:
1) safe 
2) effective
3) generally accepted national standard of medical practice 
4) not provided primarily for convenience of the patient or the practitioner 
5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested health service is medically necessary, because it is consistent with generally accepted national standard of medical practice.

Continuous, or split-shift, personal care service is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the provider five hours daily of uninterrupted sleep during the aide's shift.

This patient has multiple chronic conditions resulting in impaired gait and limited upper extremity range of motion.  Appeal letters show the patient's functional status declined after hospitalization due to COVID.  The requested service at 24 hours, split shift PCW (personal care worker) services were denied.  He was approved for 24 hours per day, live-in PCW (personal care worker) services.  The patient lives alone and does not have informal support.  UAS (Uniform Assessment System) evaluation performed shows the patient requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living).  The amount of assistance required is extensive to total dependence.  In addition, the patient is incontinent of bowel and bladder.  Logs provided show the patient receiving assistance throughout the day with less than five hours between providing assistance.  Appeal letter from the patient's provider indicates assistance needed with ADLs (activities of daily living) as accounted for in the UAS (Uniform Assessment System) evaluation, as well as need for turning/repositioning that would not allow the aide to get five consecutive hours of sleep.  This information provided demonstrates that the patient has continuous needs that cannot be met with the approved 24 hour, live-in PCW (personal care worker) services.  The frequency of care needed would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.  The proposed increase to a 24 hours, split-shift PCW (personal care worker) services is medically necessary to meet this patient's need for assistance with ADLs (activities of daily living) and personal care.