Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension/hyperlipidemia
Treatment: Personal care Service 
The insurer denied Personal care Service to 24 Hours a Day, 7 Days a Week - Split-Shift. The health plan's determination is overturned. 

The patient is a male with past medical history of hypertension, hyperlipidemia, diabetes mellitus, memory loss, obstructive sleep apnea, depression, gastroesophageal reflux disease (GERD), kidney stones, bell's palsy, migraines, chronic kidney disease, gait disorder, status/post (s/p) lobectomy of the lung, goiter, urinary incontinence, bowel incontinence, and pulmonary embolism who had been hospitalized with subsequent Skilled Nursing Facility (SNF) stay with planned discharge to home who underwent an assessment tool and was assessed at extensive assistance with tasks of meal preparation, ordinary housework, stairs, shopping, and transportation while limited assistance with tasks of managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed as independent with tasks of bed mobility and eating. The patient was assessed at extensive assistance with tasks of managing medication, phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, and transfer toilet while limited assistance with tasks of bed mobility and eating. 

The Personal care Service to 24 Hours a Day, 7 Days a Week - Split-Shift is medically necessary for this patient. 
The patient has documented progressive and worsening medical conditions with multiple hospitalizations, lung resection surgery, Covid 19 infection, and blood loss anemia with change in functional status due to these conditions. The patient has ADL/ Instrumental activities of daily living (IADL) care needs that are unscheduled and span a continuum of time and the insurer failed to document a plan that would meet these needs. The patient has urinary and bowel incontinence and needs assistance with bathing, personal hygiene, bed mobility, transfer toilet, toilet use, walking, and locomotion which are unscheduled and unpredictable needs for this patient. His needs cannot be met with supplies and/or adaptive equipment. The patient has care needs in the overnight hours as documented by overnight logs that would not allow a PCA (personal care assistant) 5 hours of uninterrupted sleep. The increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Because the patient has unscheduled and unpredictable care needs over 24 hours, the assessment tool should not have been utilized in calculating PCA hours. The plan incorrectly noted the patient did not have change in assistance with tasks as compared to previous assessment tool. Taking into account the plans 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 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.