Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence
Treatment: Increase in personal care hours, 24 hours a day 7 days a week (split shift)
The insurer denied: Increase in personal care hours, 24 hours a day 7 days a week (split shift)
The denial is: Overturned

The patient is a female with medical history notable for fall with hip fracture, gait abnormality, hypertension, anemia, chronic obstructive pulmonary disease (COPD) on oxygen, and incontinence. The patient is currently approved for 8 hours per day, 7 days per week (56 hours per week) of personal care services. The patient and her 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.

The patient is currently residing in a nursing home for short term rehabilitation and is awaiting the outcome of this appeal as part of a safe discharge plan. A letter of support for this increase in hours was provided by the patient's physician. The letter states that the patient had previously been doing well, living by herself in an apartment with 8 hours per day of personal care assistance. However, since her hospitalization and admission to short term rehabilitation, she now requires "around the clock supervision and total care with all toileting and diaper changing needs on an hourly basis." Furthermore, the patient has developed pressure ulcer wounds on the sacrum and heels and requires turning and repositioning every 2 hours throughout the day and night.
A letter of support for this appeal was provided by a community advocate. The letter also describes the patient's pressure ulcers on the bilateral heels and sacrum. The patient requires repositioning every 2 hours to promote healing. The letter also states that she has bowel and bladder incontinence and requires assistance with changing diapers.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was performed via teleconference at the rehabilitation facility. Cognition was minimally impaired; she was alert and oriented to self and place only with short term, procedural, and situational memory loss. She is "not self-directing and unable to make needs known." From a functional standpoint, she requires total dependence for meal preparation and housework. She requires maximal assistance for medications, shopping, stairs, and transpiration. For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene and dressing upper body. She requires limited assistance for bed mobility and eating. She is frequently incontinent of urine and uses pull ups for incontinence care.

The requested health service of increase in personal care services, 24 hours a day, 7 days a week (split shift) is medically necessary for this patient.
The patient has personal care needs which warrant an increase to 24 hour continuous care. She has incontinence which occurs throughout the day and night which requires diaper changes. She has pressure ulcers which are evidence that she requires turning and repositioning in bed every 2 hours; this is required both to promote healing of her current ulcers and also to prevent new ones from forming. Her physician attested to the medical necessity of turning and repositioning every 2 hours. For patients that have personal care needs that occur throughout the day and night without interruption, continuous 24 hour (split-shift) care is medically necessary. Failure to provide for these personal needs could result in further skin breakdown and/or infection.