Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Wheelchair bound
Treatment: Consumer directed personal assistant-24 hour split shift services.
The insurer denied Consumer directed personal assistant-24 hour split shift services.
The determination is overturned.

This is a female patient with a medical history notable for congestive heart failure, colon cancer, and wheelchair bound status. The patient was approved for 56 hours per week of personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift) and this request was partially denied by the health plan; they did approve an increase to 24 hours per day (live-in).
The patient's daughter provided a letter of support for this appeal. The letter states that the patient is oxygen dependent and requires constant oversight and supervision to ensure her oxygen is in place. She requires frequent overnight assistance for toileting, transfers, and repositioning in bed. The letter includes an overnight log which details personal care needs every 1-2 hours, including assistance with toileting, nebulizer treatments, oxygen, repositioning due to pain, and transfers. The patient's daughter has been voluntarily assisting with these overnight needs, but she states she is no longer able to do so in the future.
A letter of support for this appeal was provided by the regional coordinator of a community emergency response team. The letter describes a home call in which the patient was experiencing delirium and altered mental status. She was hypoxic due to not being on enough supplemental oxygen after her cannula had come off during the night. This triggered an episode of rapid atrial fibrillation and altered mental status.
A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted via teleconference. The patient was alert and oriented times three with periods of forgetfulness. She was self-directing and able to make her needs known. For her instrumental activities of daily living (IADLs), she requires total dependence for housework, stairs, and shopping. She requires maximal assistance for meal preparation and transportation. For her activities of daily living (ADLs), she requires total dependence for locomotion and toilet use. She requires maximal assistance for bathing, dressing lower body, and toilet transfer. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. Following a hospitalization for respiratory failure, she has been oxygen-dependent and wheelchair-bound. She is a two-person lift for transfers. She is on 4 liters (L) of oxygen around the clock and has episodes of desaturation to 80 percent (%) overnight when her oxygen accidentally comes out. She is frequently incontinent of urine and infrequently incontinent of stool. She uses pull-ups for incontinence care. Compared with a prior assessment, she showed a functional decline across multiple domains. At issue is the medical necessity of consumer directed personal assistant-24 hour split shift services.

The requested health service of consumer directed personal assistant- 24 hour split shift services is medically necessary for this patient.
The patient's functional status has declined following her January hospitalization for hypoxic respiratory failure. She is wheelchair bound. She is incontinent and reliant on others for toileting and incontinence care. Her personal care needs are continuous and unscheduled, and she will require around-the-clock personal care. Night logs demonstrate that it is not possible for a live-in personal care aide to get the required amount of rest (total of 8 hours with at least 5 hours uninterrupted). The patient will require toileting and diaper changes as needed in addition to oxygen adjustments and nebulizer treatments. Failure to provide for her personal care needs could result in skin breakdown, infection, and/or respiratory failure.