Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence
Treatment: Increase in personal Care Services to 24 hours a day 7 days a week (split-shift) (168 hours per week)
The insurer has denied: increase in personal Care Services to 24 hours a day 7 days a week (split-shift) (168 hours per week) 
The denial is: Overturned

The patient is a female with medical history notable for multiple recent hospitalizations, atrial fibrillation, coronary artery disease, history of rectal perforation with colostomy and reversal, and recent admission for COVID pneumonia. The patient is approved for 7 hours per day, 7 days per week (49 hours per week) of personal care services. The patient's care team requested an increase to 24 hours per day (split-shift), 7 days per week (168 hours per week) to allow for her safe discharge from a subacute care facility. This request was denied by the insurance plan, and this denial is the subject under review.

A letter of medical necessity for this appeal was provided by the patient's provider at the skilled nursing facility. The letter states that the patient is stable for discharge back to her home in the community, but that to safely do so she would require 24 hour split-shift care.

An additional letter was provided from an employee of the nursing facility; the letter writer's title and role were not included. The letter states that she is currently receiving 24 hour assistance and will continue to require this at home. She has incontinence which leads to unpredictable personal care needs, and assistance will be required to prevent urinary tract infections.

Physical therapy notes were provided for review. They note a decline in functional status as a result of recent hospitalizations, with opportunity for improvement given prior higher level of status. Their notes reflect the patient's need for hands on assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). Occupational therapy notes provide similar documentation.

A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was modified independent, with some difficulty in new situations. She was oriented times three with periods of forgetfulness. She requires total dependence for housework and maximal assistance for meal preparation. She requires extensive assistance for managing medications. She requires maximal to extensive assistance for all ADL's. She is able to take a couple of steps with a walker and maximal staff assistance. She had multiple falls at night while attempting to use the bathroom. She has urinary incontinence but is currently using an indwelling catheter. She is occasionally incontinent of stool and uses pull ups. An Hours Evaluation for Paraprofessional Support (HELPS) assessment associated with the UAS recommended 52.5 hours per week to address her functional care needs.

The health plan's determination is overturned.

The requested increase in personal Care Services to 24 hours a day 7 days a week (split-shift) (168 hours per week) is medically necessary for this patient. The patient has had a clear functional decline following multiple hospitalizations and surgeries over the course of the year. The skilled nursing facility that she is currently residing in has documented her need for personal care assistance 24 hours per day. Given that she needs hands on assistance for all personal care activities, it is medically necessary that she have assistance 24 hours per day. She has documented nighttime personal care needs which would preclude the use of a live-in aide. In addition to using the bathroom multiple times per night, she has skin tears on her arms and legs which speak to her need for turning and positioning in bed to allow for proper healing. To allow her safe discharge from the nursing facility, split-shift 24 hour care is medically necessary.