Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression, chronic obstructive pulmonary disease, oxygen dependent, hypertension, osteoarthritis, osteoporosis, and dementia.
Treatment: Increase Personal Care Aide Hours to 7 Days a Week 2-12 Hours a Day (Split Shift)
The insurer denied: Increase Personal Care Aide Hours to 7 Days a Week 2-12 Hours a Day (Split Shift)
The denial is overturned

The patient is an elderly female. Her conditions include depression, chronic obstructive pulmonary disease, oxygen dependent, hypertension, osteoarthritis, osteoporosis, and dementia. She is status post-surgery for right hip fracture 4 months ago. The denial of increase in personal care aide hours to 7 days a week 2-12 hours a day (split shift) is being appealed. The health plan approved 7 days per week for 9 hours per day.
Uniform Assessment System (UAS) evaluation completed 2 months ago shows minimally impaired cognition and functional status: total dependence with housework and locomotion; maximal assistance with meal preparation, managing finances, shopping, bathing, lower body dressing, and toileting; extensive assistance with managing medications, phone use, personal hygiene, upper body dressing, bed mobility, and eating. The patient is recently non-ambulatory due to hip fracture. She has bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed four months ago, there has been a decline with cognition, managing finances, bathing, toileting, locomotion, and eating. An appeal letter from a licensed clinical social worker report states that the patient is bedridden and has urinary incontinence and required diaper changes every 2 to 4 hours, and that the patient needs help with position change every 2 hours. A letter from the patient's provider notes that the patient's recent hip fracture was complicated by COVID (coronavirus disease). These events have worsened the patient's dementia, shortness of breath, anxiety, and inability to ambulate. She is bedridden and has skin irritation due to urinary incontinence. 

The requested Increase Personal Care Aide Hours To 7 Days A Week 2-12 Hours A Day (split shift) 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. The denial of an increase in personal care aide hours to 7 days a week 2-12 hours a day (split shift) is being appealed. The health plan approved 7 days per week for 9 hours per day. This patient has multiple chronic conditions, including recent COVID and hip fracture, resulting in her being bedridden. Uniform Assessment System (UAS) evaluation completed 2 months ago shows the patient requires extensive assistance to total dependence with all activities of daily living (ADLs). She is incontinent of bowel and bladder. Compared to Uniform Assessment System evaluation completed 4 months ago, there has been a decline with cognition, managing finances, bathing, toileting, locomotion, and eating. The appeal statements and night logs support the patient is dependent with all activities of daily living and requires frequent assistance with toileting, transfers, and turning/repositioning. 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 aide hours of 7 days per week for 9 hours per day is inadequate to meet this patient's needs. The requested increase in personal care aide hours to 7 days a week 2-12 hours a day (split shift) is medically necessary.