Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypothyroidism, anxiety and depression.
Treatment: Increase Personal Care Worker (PCW) Services To 7 Days per Week, 24 Hours per Day, Continuous Split Shift by More than One Person, for 168 Hours per Week.
The insurer denied the Increase Personal Care Worker (PCW) Services To 7 Days per Week, 24 Hours per Day, Continuous Split Shift by More than One Person, for 168 Hours per Week.

The denial is overturned.

This is a female with conditions including dementia, hypothyroidism, anxiety and depression.  She was discharged from NH (nursing home) after a three week stay for rehab following a hip fracture.  She lives alone in a house - her husband recently died.  The patient is appealing denial of personal care worker (PCW) services, seven days per week, 24 hours per day, split shift.  She has been approved for seven days per week, 24 hours per day, live-in, 91 hours per week.  

Assessment performed shows severely impaired cognition  and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, bathing, personal hygiene, dressing, and toileting; and extensive assistance with bed mobility and eating.  She is lifted from bed to chair; unable to stand on her own.  She uses a wheelchair and scooter for locomotion.  She is frequently incontinent of bowel and bladder.  The letter dated the provider states the patient's condition is worsening. The doctor states the patient needs diapers changed during the day and night.  She puts her hands in soiled diapers and needs proper skin care to avoid bedsores.   Appeal letter from the patient's daughter states the patient needs assistance with activities of daily living (ADLs) as already accounted for in the assessment.

The proposed treatment is 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 proposed treatment is medically necessary because it is 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 patient was approved for personal care worker (PCW) services 91 hours per week.  This is an appeal of the denial of 24 hour, split shift, personal care worker (PCW) services.  The patient has multiple chronic medical conditions, including late-stage dementia.  She has a recent hospitalization after a hip fracture.  Assessment performed shows the patient requires extensive assistance to total dependence with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs).  She lives alone.  She is unable to transfer from the bed to chair.  She is incontinent of bowel and bladder and requires diaper changes during the day and night.  The appeal letters show the patient has poor functional status and deteriorating conditions.  She requires significant assistance including diaper changes and bed mobility that occur throughout the entire day.  The approved 91 personal care worker (PCW) services per week are inadequate to meet the patient's needs with activities of daily living and instrumental activities of daily living as noted above.  The proposed increase in personal care worker services to 24 hours, split shift, is medically necessary to meets this patient's need for assistance with activities of daily living (ADLs) and personal care.