Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/ Other/Dementia

Treatment: Home Health/Personal Care Worker (PCW) Services: 7 Days per Week x 24 Hours per Day, Continuous Care by More Than One (1) Person, 168 Hours per Week.

The health plan denied the requested Personal Care Worker (PCW) Services: 7 Days per Week x 24 Hours per Day, Continuous Care by More Than One (1) Person, 168 Hours per Week. 

The health plan's determination is upheld.

This is a case review for a female with a medical history notable for dementia, incontinence, and mobility issues. The patient is approved for 6 hours per day, 7 days per week (42 hours per week) of Personal Care Worker (PCW) services. The patient and her care team requested an increase to 24 hours per day continuous care by more than one person (split-shift), 7 days per week (168 hours per week).
The patient's physician provided a letter of support for this appeal. The letter states that the patient requires assistance with all activities of daily living (ADL), including turning and repositioning throughout the night to prevent pressure ulcers. The patient lives alone. Because of these needs, the physician requests split-shift care.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in-person. The patient lives alone in an apartment. She was alert and oriented to person and place only with impaired cognition. For her instrumental activities of daily living (IADL), she requires total dependence for housework. She requires maximal assistance for meal preparation, finances, stairs, shopping, transportation, and equipment management. She requires extensive assistance for medications. For her ADL, she requires extensive assistance for bathing and dressing. She requires limited assistance for hygiene, walking, locomotion, toilet transfer, and toilet use. She is independent for bed mobility. The patient was observed ambulating and transferring with the use of a walker. She is frequently incontinent of urine and continent of stool. Compared to prior UAS from earlier, she showed a decline in functional status.
At issue is the medical necessity for the requested health service/treatment of Personal Care Worker (PCW) Services: 7 days per week x 24 hours per day, continuous care by more than one (1) person, 168 hours per week.

The health plan's determination of medical necessity is upheld, in whole.

The requested health service of Personal Care Worker (PCW) Services: 7 days per week x 24 hours per day, continuous care by more than one (1) person, 168 hours per week has not been demonstrated to be medically necessary for this patient.
Continuous care services by more than one person ("split-shift" services) are medically necessary when a patient has personal care needs that are continuous and unscheduled throughout the day and night. There is insufficient documentation to determine what personal care needs, if any, the patient has that require continuous care throughout the night. The physician letter requests split-shift service for assistance with turning and repositioning to prevent bed sores; however, the UAS states that the patient is independent in bed mobility. There is no discussion of need for assistance with night time toileting needs. Therefore, there is insufficient evidence that continuous 24 hour care is medically necessary for the patient.