Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke/CVA
Treatment:  Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hour(s) per Day (Split Shift)
The health plan denied: Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hour(s) per Day (Split Shift)
The determination is: Overturned

This is a female patient with a history of diabetes mellitus type 2, cerebrovascular accident (CVA), hemiplegia of right dominant side, coronary artery disease, osteoarthritis, and bladder incontinence. She lives alone. The patient was previously approved for Personal Care Services for 49 hours per week. The patient and her care team requested Personal Care Services increase to 24 hours per day (split shift). The Plan partially denied this request and approved 24 hours per day (live in).
A video Uniform Assessment System (UAS) was completed. The patient was assessed at total dependence for tasks of meal preparation, ordinary housework, managing finances, managing medications, phone use, stairs, shopping, transportation, and locomotion; maximal assistance with tasks of bathing, personal hygiene, dressing upper body, dressing lower body, walking, transfer toilet, and eating; and extensive assistance with bed mobility. A tasking tool was used to determine that she requires 49.2 hours of aide service per week.
Overnight care logs were provided. These logs show that the patient consistently required assistance with activities of daily living (ADLs) of changing her diaper and being turned and repositioned every 2-4 hours overnight.
The patient's primary care physician (PCP) provided a letter of support. He states that she requires assistance with all ADLs, including turning and repositioning throughout the night hours to prevent bed sores. Her PCP states that she must be repositioned every two to four hours throughout the day and night. He recommends 24-hour split-shift care.
The patient's advocate provided a letter of support. Her advocate states that the patient wears pull-ups that need to be changed 3-5 times per night to prevent skin conditions.
Personal Care Services increase to 24 hours per day (split shift) is medically necessary.
Per New York (NY) Codes, Rules, and Regulations section 505.14, a live-in personal care aide must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. An aide to this patient would be unable to receive five hours of uninterrupted sleep for two reasons. First, the patient's PCP documented the need for the patient to be turned and positioned every two to four hours, which is typically recommended for the purpose of preventing pressure injuries. As noted in "Pressure Injuries: Prevention, Evaluation, and Management," prevention measures in patients at increased risk of pressure injuries include keeping skin clean (particularly following incontinence events) and encouraging patients to change positions often, with assistance if necessary. Increased moisture from urine, stool, and sweat can cause skin maceration and escalate the risk of pressure injuries. There is documentation in the UAS of the patient requiring maximal assistance with tasks of transfer toilet and toilet use and extensive assistance with bed mobility. Secondly, the overnight care logs provided by the patient's aide show that the patient requires assistance with changing her diaper or turning and positioning every two to four hours. Therefore, split-shift care is required to meet the patient's frequent care needs.
In addition, there is documentation from the patient's PCP of medical necessity of increased services. The patient lives alone and does not have informal support for the entire time outside of the previously assigned hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in personal care services is not solely for safety and supervision but to assist the patient with ADLs.