Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, coronary artery disease, breast cancer, colon cancer, and decubitus ulcer
Treatment: Increase Home/Personal Care HHC Level 2 to 24 Hours A Day (Split Shift)
The insurer denied: Increase Home/Personal Care HHC Level 2 to 24 Hours A Day (Split Shift)
The denial is overturned.

The patient is an elderly female. Her medical conditions include dementia, coronary artery disease, breast cancer, colon cancer, and decubitus ulcer. She lives alone. Denial of increase 
home/personal care to 24 hours a day (split shift) is being appealed. The health plan approved 24 hours per day (live-in).
The patient's Uniform Assessment System (UAS) evaluation completed 5 months ago show moderately impaired cognition and functional status: maximal assistance to total dependence with ADLs (activities of daily living), expect extensive assistance with phone use, personal hygiene, and bed mobility. She has frequent incontinence. Compared to UAS (Uniform Assessment System) evaluation completed 9 months ago, there has been a decline in functional status. Appeal statements report that the patient is bedbound. She had a hip fracture earlier this year after a fall and is status post repair. Her self-sufficiency has deteriorated, and she needs assistance with ADLs (activities of daily living). She has frequent bladder incontinence. She has a colostomy. Her providers report she needs turning and repositioning every two hours.

The requested Increase Home/Personal Care to 24 Hours A Day (Split Shift) is medically necessary.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. 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. Denial of increase home/personal care to 24 hours a day (split shift) is being appealed. The health plan approved 24 hours per day (live-in). This patient has multiple chronic conditions, including recent repair of hip fracture. The health plan noted that there are no compelling nighttime needs. Uniform Assessment System (UAS) 
evaluation completed 5 months ago shows the patient requires maximal assistance to total dependence with ADLs (activities of daily living), expect extensive assistance with phone use, personal hygiene, and bed mobility. She is bedbound. She is incontinent of bladder. Compared to prior UAS (Uniform Assessment System) evaluation completed 9 months ago, there has been a decline in her functioning. The appeal statements support the patient is dependent with ADLs (activities of daily living), is bedbound and requires frequent nighttime assistance with turning/repositioning. Her providers report the need for repositioning every two hours. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved personal care, 24 hours per day, live-in, is inadequate to meet her needs for assistance with day and nighttime ADLs (activities of daily living). The requested increase to 24 hours per day, split shit, is indicated and medically necessary.