Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence/Urinary/Bladder Control
Treatment: Personal Care Aide (PCA) 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift), for a total of 168 hours per week
The health plan denied: Personal Care Aide (PCA) 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift), for a total of 168 hours per week
The determination is: Overturned

The patient is a male with medical history notable for dementia, incontinence, and gait disturbance. The patient is currently approved for 24 hours per day (live-in), 7 days per week of personal care services. The patient and his care team requested an increase to 24 hours per day (2-12-hour split-shift), 7 days per week (168 hours per week), and this request was denied by the insurance company. This denial is the subject under review.
A letter of medical necessity for this appeal was provided by the patient's physician. The letter states that the patient had a recent fall and was admitted to the hospital. While in the hospital he also was treated for pneumonia. As a result of this, he has "deteriorated significantly and is now bedbound." He is unable to "turn sides in bed independently. Patient's skin is fragile." The physician requests personal care assistance with repositioning in bed every 2-3 hours during the day and night to prevent his pressure ulcers from getting worse. He also requires frequent diaper changes due to his urinary incontinence. The physician requests continuous personal care to address his needs both during the day and night.
A community advocate provided a letter of support for this appeal. This was reviewed in detail and outlines many of the same concerns raised by the patient's physician.
A Uniform Assessment System (UAS) was most recently completed and was available for review. The patient was alert and oriented times two and is unaware of his physical limitations and unable to direct his own care. He requires total dependence for nearly all Instrumental activities of daily living (IADL). For his activities of daily living (ADL), he requires maximal assistance or total dependence for all. He requires maximal assistance for bed mobility and total dependence for toileting. He is frequently incontinent of stool and urine.
At issue is the medical necessity of the requested health service/treatment of Personal Care Aide (PCA) 24 hours per day - 7 days per week (split shift), for a total of 168 hours per week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service of Personal Care Aide (PCA) 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift), for a total of 168 hours per week is medically necessary for this patient.
The physician's letter of support for this appeal provides justification of the medical necessity for this appeal. The patient requires turning and repositioning every 2-3 hours all day and night, and he cannot do this independently. He is also incontinent of stool and urine and cannot manage his own incontinence care. His personal care needs are continuous and expected to occur without a night-time break. This makes split-shift care medically necessary to meet the personal care needs of this patient.