Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bed bound status
Treatment: Personal Care Worker (PCW) service 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person.
The insurer denied Personal Care Worker (PCW) service 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person.
The determination is overturned.

This is a female patient with a medical history notable for bed bound status, incontinence of urine and feces, and unsteady gait. The patient was approved for 24-hour per day split shift care, 7 days per week, for a total of 168 hours per week. The health plan decided to reduce her personal care service to 24-hour per day live in personal care, 7 days per week for a total of 91 hours per week.

The patient's physician provided a letter of support. The patient is currently in a skilled nursing facility. The patient requires extensive assistance to total dependence for all activities of daily living including transfers, toileting, and mobility. She has a history of frequent urinary tract infections and requires assistance with using the bathroom and for incontinence care. The physician attests that the patient requires turning and repositioning every two hours throughout the day and night.

A Uniform Assessment System was completed. The patient lives alone in an apartment. She was alert and oriented to person and place only with forgetfulness at times. Cognition was moderately impaired. Her mini-mental status examination shows a score of 16 out of 30, consistent with moderate dementia. For her instrumental activities of daily living the patient requires maximal assistance or total dependence for essentially all. For her activities of daily living, the patient requires maximal assistance for bathing, dressing lower body, toilet use, and bed mobility. She requires extensive assistance for hygiene, dressing upper body. She requires limited assistance for eating. The patient is frequently incontinent of both urine and stool. At issue is the medical necessity of Personal Care Worker (PCW) service 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person.

The requested health service of Personal Care Worker (PCW) service 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person is medically necessary for this patient.
The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5 hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. 
The patient has care needs which are expected to be continuous and unscheduled throughout the day and night and would preclude adequate rest from a live-in personal care aide. The patient has a pressure ulcer which requires frequent turning and repositioning, and she requires maximal assistance with bed mobility. She has frequent episodes of both urinary and fecal incontinence and is unable to manage her own incontinence care. She is also unable to direct her own care and will need frequent diaper changes in toileting overnight as directed by the personal care aide. Therefore, a live-in personal care aide would not be able to receive adequate rest at night. 24-hour split shift care for a total of 168 hours per week is medically necessary for the patient.