Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical Quadriplegia. 
Treatment: Increase in Personal Care Services to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week. 
The insurer denied coverage for increase in Personal Care Services to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week. 
The denial is overturned. 

The participant is a patient diagnosed with cervical quadriplegia, C (cervical) 5-C7 incomplete, spasticity, lumbago, constipation, incontinence, high cholesterol, kyphoscoliosis, diabetes mellitus without complication, myofascial muscle pain. The participant lives alone in 1 bedroom with no informal support.  The patient's medical condition puts them at risk for skin breakdown. The assessment shows that the patient is totally dependent for meals, housekeeping, shopping, laundry, toileting, dressing, personal hygiene, locomotion, transfers, bed mobility and eating. The assessment showed that the patient spends most of their time in bed and is incontinent of bowel and bladder. The patient uses a bedside commode and incontinent supplies. The patient uses a motorized wheelchair for mobility. Service recommendations were for skin barrier cream after diaper changes, a special mattress for pressure relieving and a transferring device to help transfers; position pillows and heel protector for skin protection. The patient is currently receiving 24 hours/7 days live-in personal care services (PCS). The patient is requesting 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week. 

The insurer denied coverage for an increase in Personal Care Services to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week based on the fact that the patient spends most of their time in bed. They have a bedside commode and incontinent supplies to help them stay dry. The plan suggests using a barrier cream with each diaper change to reduce exposure of their skin to moisture and limiting the amount of fluids. The participant drinks 2-3 hours before bedtime. The current approved hours of 24 hours a day, 7 days a week, live-in for a total of 91 hours a week can meet the patient's needs and allow the aide to obtain at least 5 hours of uninterrupted sleep in an 8-hour period. 

The patient's doctor submitted an appeal letter noted that the patient has tetraplegia, spasticity, lumbago, incontinence, and diabetes. The patient requires dependence on others for all ADL's (Activities of Daily Living). The patient has chronic pain and is incontinent of stool and urine requiring incontinence care at least 6 times daily including during the night. The patient required repositioning every two hours due to having a high risk of skin breakdown. The patient also requires administration of medications including pain medications. The letter also indicated that the participant would require 24 hours care via split shift. 

In the case the patient is totally dependent for meals, housekeeping, shopping, laundry, toileting, dressing, personal hygiene, locomotion, transfers, bed mobility and eating.  The participant is currently approved for 24 hours a day, 7 days a week, live-in for a total of 91 hours a week. Based on the information provided, the denial of coverage for an increase in Personal Care Services to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week is reversed as medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in Personal Care Services to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week is substantiated.