Appeal type: Medical necessity
Decision: Upheld

Diagnosis: status post COVID, dementia, lung cancer, hypertension, coronary artery disease, urinary incontinence, fecal incontinence, diabetes with implications, chronic low back pain, osteoarthritis, and dizziness
Treatment: Increase Personal Care Services Level 2 To 24 Hours Per Day, 7 Days Per Week (split shift) A Total 168 Hours
The insurer denied the Increase Personal Care Services Level 2 To 24 Hours Per Day, 7 Days Per Week (split shift) A Total 168 Hours
The denial is upheld. 

The patient is a male. His conditions included status post COVID, dementia, lung cancer, hypertension, coronary artery disease, urinary incontinence, fecal incontinence, diabetes with implications, chronic low back pain, osteoarthritis, and dizziness. He lives alone in an apartment. The appeal is regarding denial of PCS (personal care service) 24 hours per day, split-shift. He has been approved for PCS (personal care service) 24 hours per day, live-in.

UAS (Uniform Assessment System) evaluation performed shows moderately impaired cognition and functional status: total dependence with meal preparation, and shopping; maximal assistance with managing medications, phone use, bathing, dressing, and toilet transfer; extensive assistance with personal hygiene, walking, locomotion, toilet use, bed mobility, and eating. The patient's physical activity is less than one hour. His DME (durable medical equipment) includes rolling walker, hospital bed, bed rails, commode, grab bars, and raised toilet seat. He is frequently incontinent of bladder and occasionally incontinent of bowel.

An appeal letter from the provider notes that the patient has fallen three times when trying to get out of bed at night. He was hospitalized due to COVID and has fatigue, cough and shortness of breath. The letter notes that the patient is mostly bedbound and cannot stand on his own. He needs help for position changes. It further notes that the patient's condition is constantly deteriorating and he cannot care for himself. The letter recommends split-shift PCS (personal care service).

No, the increase in Personal Care Services Level 2 to 24 Hours Per Day, 7 Days Per Week (split shift) for a total of 168 Hours is not medically necessary.
Medically necessary services are those which are:
- safe 
- effective
- generally accepted national standard of medical practice 
- not provided primarily for convenience of the patient or the practitioner 
- the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested health service is not medically necessary, because it is not consistent with generally accepted national standard of medical practice.

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 provider five hours daily of uninterrupted sleep during the aide's shift. This appeal is regarding denial of PCS (personal care service) 24 hours per day, split-shift. He has been approved for PCS (personal care service) 24 hours per day, live-in.

This patient has multiple chronic conditions. The UAS (Uniform Assessment System) evaluation performed shows he requires assistance with all ADLs (activities of daily living) and personal care needs. He has fallen several times and is at risk for falling. An appeal letter from his doctor notes that the patient is mostly bed bound and needs assistance with position changes. However, it does not indicate the necessity for timed turning/repositioning and there is no documentation of need for scheduled turning/repositioning that would prevent the aide from obtaining five hours of uninterrupted sleep.  PCS (personal care service) is not indicated for management of chronic medical conditions or when there are no tasks being performed. The documentation does not support that this patient needs uninterrupted care that would prohibit the aide from getting five hours daily of uninterrupted sleep during the aide's shift. The proposed increase to PCS (personal care service) to 24 hours per day, split shift is not medically necessary to meet this patient's needs.