Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aortic stenosis, urinary tract infection (UTI), sepsis and dementia. 
Treatment: Personal care aide, continuous care split shift services. 

The insurer denied coverage for personal care aide, continuous care split shift services. 
The denial is overturned. 

The patient is of advanced age with a history of iron deficiency anemia, aortic stenosis, urinary tract infection, sepsis, and dementia. She has had recent hospitalizations. Per the Uniform Assessment System (UAS) Report, the patient requires extensive assistance-dependence with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She has no control over bladder or bowel. Split shift services are requested. 

In a letter, her physician notes that the patient is still in a rehabilitation facility. The patient is oriented to self only. She requires extensive assistance with bed mobility, transfers, toileting, bathing, turning, and positioning. She has a heel pressure sore. She has an indwelling urinary catheter. 

The reviewer disagrees with the plan's decision. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes: 

"(a) Definitions and scope of services. 

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse. 

***(2) Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.... 4) Live-in 24-hour personal care services means the provision of care by one personal care aide for a patient who, because of the patient's medical condition, needs assistance during a calendar day with toileting, walking, transferring, turning and positioning, or feeding and whose need for assistance is sufficiently infrequent that a live-in 24-hour personal care aide would be likely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep. 

The patient has an indwelling catheter so urinary incontinence is not an issue, but the catheter bag needs to be emptied. Even with the catheter she has unscheduled needs for bowel movements and should not be allowed to be in a soiled diaper for hours. She already has heel skin breakdown and needs turning and positioning every 2 hours and cannot do it herself. 

Due to the above the request for split shift is approved. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for personal care aide, continuous care split shift services is overturned. Medical necessity is substantiated.