Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, diabetes, hypertension, neuropathy, and dementia.
Treatment: Increase Personal Care Services To 24 Hours Per Day (split shift -12 hours x 2 shifts per day).
The insurer denied: Increase Personal Care Services To 24 Hours Per Day (split shift -12 hours x 2 shifts per day).
The denial is overturned.

The patient is an elderly male. His medical conditions include stroke, diabetes, hypertension, neuropathy, and dementia. Denial of increase personal care services to 24 hours per day, split shift - 12 hours x 2 shifts per day, is being appealed. The health plan approved personal care services - 24 hours per day, live-in, 7 days per week.

Uniform Assessment System evaluation performed earlier this year shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, and transportation; maximal assistance with managing medications, bathing, lower body dressing, walking, locomotion, and toileting; extensive assistance with managing finances, phone use, personal hygiene, upper dock dressing, and bed mobility; and limited assistance with eating. The patient has bowel and bladder incontinence. Statements from the patient's provider note the patient has multiple medical problems and was admitted to an acute inpatient level of care and then he was admitted to a rehab. 

The patient's health has been deteriorating over the past few months. He is bedbound and needs position changes every two hours. He requires diaper change, maximal assistance with transfers, and nighttime assistance. The provider notes the patient is unable to care for himself due to confusion and compromised mobility.

The requested Increase Personal Care Services To 24 Hours Per Day (split shift -12 hours x 2 shifts per day) 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. The denial of increase personal care services to 24 hours per day, split shift -12 hours x 2 shifts per day, is being appealed. The health plan approved personal care services - 24 hours per day, live-in, 7 days per week. 

This patient has multiple chronic conditions, including recent admission earlier this year. Uniform Assessment System evaluation performed this year shows the patient requires assistance with all ADLs (activities of daily living). He is incontinent of bowel and bladder. The appeal statements note the patient's medical condition has deteriorated over the past few months. He is bedbound and needs turning every two hours. The appeal statement notes the patient requires nighttime assistance. Based on the appeal statement, the 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 services 24 hours per day, live-in, 7 days per week is inadequate to meet the patient's needs. The requested increase personal care services to 24 hours per day, split shift -12 hours x 2 shifts per day is medically necessary.