Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Osteoarthritis.
Treatment: Personal care services - 24 hours a day, 7 days a week (split shift) for a total of 168 hours.
The insurer denied Personal care services - 24 hours a day, 7 days a week (split shift) for a total of 168 hours.
The determination is overturned.

The patient has a medical history of dementia, diabetes mellitus type 2, glaucoma of the right eye, vision loss of the left eye, osteoarthritis of the cervical (C)-spine and lumbar (L)-spine, end stage renal disease (ESRD) on hemodialysis, coronary artery disease (CAD), status post percutaneous coronary angioplasty, osteoarthritis of bilateral knees, severe protein-calorie malnutrition, diabetic neuropathy, cancer of the sigmoid colon, urinary incontinence, and bowel incontinence and had been assigned personal care assistant (PCA) services 10 hours/day, 4 days/week and 7 hours/day, 3 days/week.
The patient sustained falls and there was a request to increase PCA services. The patient underwent an assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, transportation, bathing, dressing lower body, locomotion, toilet use, and bed mobility while maximum assistance with tasks of managing finances, phone use, personal hygiene, and dressing upper body. The patient was assessed at extensive assistance with task of managing medication, equipment management, and eating, and the assessor noted activity did not occur for tasks of walking and transfer toilet. Notes from the assessment stated the patient had a decline in activities of daily living (ADL) status and a deterioration in overall self-sufficiency over the last 90 days. The notes also stated the patient was unable to wheel himself in a wheelchair, required a Hoyer lift for transfers, and needed to be turned and repositioned every 2 hours because he was unable to do so himself.

The insurer provided an initial adverse determination denial notice denying the request to increase PCA services stating the daughter did not identify any tasks that were not being met with his current schedule, there was no medical need for him to get up at night, overnight service was for safety supervision which was not a covered benefit, they recommended an over bed table to help reach objects he may need, they also recommended a thermal plate to keep his food warm, and they recommended following up with the nursing home transition and diversion Medicaid waiver program. In addition, the denial letter stated the patient could use a bed cane to help with moving in and out of bed, they recommended an alternating mattress for his bed to reduce pressure on bony prominences, the plan also recommend physical therapy, they recommended a condom catheter at night to meet his nighttime toileting needs, the plan recommended limiting fluid intake after 6 PM to lessen nighttime urination, and they recommended splitting his hours into 2 shifts to better meet his care needs.

The patient's primary care physician (or provider) (PCP) provided a letter documenting the patient's medical diagnoses and the need for assistance to complete ADLs both day and night. The doctor noted the patient had an adult daughter who was very involved with his care but did not live with him. The PCP letter also stated that due to the patient's advanced arthritis he was bedbound and could no longer transfer without assistance and despite several episodes of physical therapy (PT) / occupational therapy (OT) he has not been successful at restoring function. The provider also noted the patient had has had frequent loose stools since his colon cancer surgery and has bowel incontinence both day and night. She noted the patient must be transferred with a Hoyer lift and although he is able to use a diaper is unable to change the diaper alone. In addition, the patient's PCP stated the patient is unaware of his incontinence and must be checked regularly and soiled diapers must be changed promptly, even in the overnight. The provider also noted the patient is unable to reheat his meals and must be able to eat a small snack in response to potential low blood glucose in the middle of the night. Lastly, the provider stated it was in her opinion that the patient required 24-hour home care and split shifts in order to maintain his health and prevent loss of further function and hospitalization and skilled nursing facility (SNF) placement was not appropriate as this was clearly against his wishes. The insurer provided a final adverse determination denial notice partially approving PCA services to 64 hours/week. The patient was seen by a visiting doctor at home for a lump in the abdomen which was felt to be a hernia although patient did not have any complaints of pain and it was determined this would be monitored.

At issue is the medical necessity of personal care services- 24 hours a day, 7 days a week (split shift) for a total of 168 hours. 

Yes, the services are medically necessary.

There is documentation of both cognitive and functional decline by the patient with a request to increase PCA services. Following the patient's colon cancer surgery, he has had bowel incontinence and is unable to transfer or change diaper. The patient requires total assistance with the tasks of walking, locomotion, transfer toilet, and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The insurer's own assessment documented the patient needed to be turned and repositioned every 2 hours in order to prevent skin breakdown. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient had participated in physical therapy and occupational therapy on multiple occasions without restoration of function. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient sometimes requires a snack in the night due to hypoglycemia from his diabetes. The patient's overnight care needs would not allow an aide to obtain at least 5 hours of uninterrupted sleep. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.