Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Post Stroke
Treatment: Personal Care Services (PCS) - 24 hours/day, 7 days/week (split-shift) for a total of 168 hours
The insurer denied PCS - 24 hours/day, 7 days/week (split-shift) for a total of 168 hours.
The denial is overturned.

The patient is an adult male. His conditions include a stroke with residual hemiparesis. His history includes HIV (human immunodeficiency virus), heart disease, hyperlipidemia, seizures, and anemia. He is wheelchair bound. He lives with his mother. Denial of personal care services (PCS), 24 hours/day, 7 days/week (split-shift) for a total of 168 hours is being appealed. The plan approved 7 hours/day, 7 days/week.

Uniform Assessment System (UAS) evaluation completed recently showed independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, transportation, bathing, lower body dressing, walking, locomotion, and toileting; extensive assistance with personal hygiene, upper body dressing, bed mobility, and eating; and limited assistance with managing finances and medications. The patient has infrequent bladder incontinence.

An appeal statement notes the patient's mother is no longer able to provide overnight assistance. Splitting the currently approved services will not cover unscheduled needs, such as toileting and transferring. His mother assists him with toileting every 1-2 hours per night. The patient requires assistance in the morning and at night for transfers.

A letter from the patient's provider notes that the patient is unable to perform ADLs (activities of daily living) and needs additional hours.

The PCS - 24 hours/day, 7 days/week (split-shift) for a total of 168 hours is medically necessary.

PCS are 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 PCS 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. Denial of PCS, 24 hours/day, 7 days/week (split-shift) for a total of 168 hours is being appealed. The health plan denied coverage of the requested services and recommended splitting the approved 7 hours/day, 7 days/week to best meet morning and evening needs.

This patient has multiple chronic conditions, including a stroke with hemiparesis. He is wheelchair bound. UAS evaluation completed recently shows the patient needs assistance with all ADLs. He is incontinent of bladder. The appeal statements support the patient is dependent with all ADLs and requires frequent assistance with transfers and toileting, including toileting every 1-2 hours at night. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved PCS for 7 hours/day, 7 days/week is not adequate to meet this patient's needs. The requested PCS for a total of 168 hours/week, split-shift, is medically necessary.