Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ischemic heart disease, dementia, osteoarthritis.
Treatment: Increase in personal care service to 24 hours a day, seven days a week (split-shift).
The insurer denied: Increase in personal care service to 24 hours a day, seven days a week (split-shift).
The denial is overturned.

This elderly female has medical conditions including ischemic heart disease, dementia, osteoarthritis, hypertension, hyperlipidemia, and coronary artery disease. She lives alone. She is appealing the denial of an increase in consumer directed personal assistance services (CDPAS) to 24 hours, split-shift care. The health plan approved consumer directed personal assistance services 70 hours per week. 
Uniform Assessment System (UAS) evaluation completed on recently shows severely impaired cognition and functional status: total dependence with managing medications; maximal assistance with bathing, personal hygiene, dressing, walking, locomotion; limited assistance with toilet transfer. She has frequent bladder and bowel incontinence. Compared to Uniform Assessment System (UAS) evaluation completed on five months earlier, there has been a decline with managing medications, personal hygiene, and dressing. An appeal statement from the patient's child states the patient is bedridden and has dementia. An appeal statement from the patient's physician recommends additional home care due to significant functional and cognitive impairment. An appeal statement from New York State notes the patient's functional and cognitive capacity have declined resulting in an increase in functional needs. She has severe cognitive impairment. She requires assistance with all activities of daily living (ADLs). She confuses day/night and wakes up at night and needs to use the bathroom three to four times per night. The appeal notes that night logs show the patient needs assistance with toileting and personal care every 2.5 to 3.5 hours during the night. An increase in hours is indicated due to physical debility, pain, poor balance, and incontinence.

The proposed treatment, increase in personal care service to 24 hours a day, seven days a week, split-shift care, 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 is appealing the denial of an increase in consumer directed personal assistance services (CDPAS) to 24 hours, split-shift care. The health plan approved consumer directed personal assistance services 70 hours per week. Uniform Assessment System (UAS) evaluation completed on recently shows the patient requires assistance with all activities of daily living. The patient is incontinent of bladder and bowel. Compared to Uniform Assessment System (UAS) evaluation completed five months earlier, there has been a decline with managing medications, personal hygiene, and dressing. Appeal statements support the need for assistance with all activities of daily living (ADLs). Appeal statements also 
indicate the need for frequent assistance during the night with toileting. This patient has continuous needs, including frequent toileting that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved consumer directed personal assistance services 70 hours per week is insufficient to meet the patient's needs for assistance with activities of daily living and personal care.

The proposed consumer directed personal assistance services 24 hours, split-shift care, is medically necessary.