Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sacral ulcer, diabetes, dementia
Treatment: Increase Personal Care Assistance Services to 24 
Hours per Day 7 Days per Week (Split Shift) Monday - Sunday, for a Total of 168 Hours per Week
The insurer denied: Increase Personal Care Assistance Services to 24 Hours per Day 7 Days per Week (Split Shift) Monday - Sunday, for a Total of 168 Hours per Week
The denial is overturned.

This elderly female patient has medical conditions that include subarachnoid hemorrhage, chronic kidney disease, hypertension, asthma, sacral ulcer, osteoporosis, anemia, gastroesophageal reflux disease (GERD), fatigue, diabetes, dementia, hearing loss, vision loss, and weakness. She was admitted to the hospital four months ago for a urinary tract infection. She lives alone. The denial of an increase in personal care assistance services to 24 hours per day 7 days per week (split shift) Monday - Sunday, for a total of 168 hours per week, is being appealed. The health plan approved 84 hours per week.
Uniform Assessment System (UAS) evaluation completed two months ago shows problems with memory and functional status: total dependence with meal preparation housework, managing finances and medication, shopping, equipment management, bathing, personal hygiene, dressing, locomotion, toilet use, and eating; maximal assistance with bed mobility; and extensive assistance with toilet transfers. She uses a wheelchair and scooter for locomotion. She has bowel and bladder incontinence. 
An appeal statement from New York State and a letter from Physician Assistant (PA) notes the patient is homebound. She has several chronic conditions that result in total assistance with activities of daily living. She needs 24/7 assistance so that she can get her diaper changed and be repositioned every three hours per night. She has no informal support.

The proposed treatment is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. 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 that 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. She was admitted to the hospital four months ago for a urinary tract infection. The denial of an increase in personal care assistance services 24 hours per day, 7 days per week (split shift) Monday - Sunday, for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week. Uniform Assessment (UAS) evaluation completed two months ago shows the patient requires extensive assistance to total dependence with all activities of daily living. She is incontinent of bowel and bladder. The appeal statements support the patient is dependent with all activities of daily living and requires frequent assistance with toileting and turning/repositioning. She lives alone and does not have informal support. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved personal care assistance services of 84 hours per week is insufficient to meet her needs for assistance activities of daily living. The proposed increase to a total of 168 hours per week, split shift, is medically necessary.