Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke.
Treatment: personal care assistance services 24 hours per day 7 days per week in split shifts for a total of 168 hours per week.
The insurer denied personal care assistance services 24 hours per day 7 days per week in split shifts for a total of 168 hours per week.
The determination is upheld.


The patient has a medical history notable for hypertension, atrial fibrillation, and cognitive impairment, who suffered an ischemic stroke and is status post thrombectomy. In her recovery, she developed a small bowel obstruction requiring surgical intervention. She was discharged from the hospital to a long-term care rehabilitation center but desired discharge home back to the community. She was previously receiving daily personal care level 2 services, and her care team requested an increase to 168 hours per week (split shift) to meet her new needs following these medical events. The health plan denied this request, stating that she has skilled nursing needs that cannot be met by level 2 personal care services, and they recommended that she remain in skilled nursing to optimize her health and safety. This denial of level 2 personal care services is under review.
Occupational therapy notes were provided. As sequelae of her recent medical events, she is now suffering from right-sided hemiparesis, dysarthria, impaired cognition, dysphagia, impaired wakefulness, impaired gait, impaired activities of daily living (ADLs)s, and sundowning. Discharge documentation from the rehabilitation facility shows that she made improvements in these domains throughout her stay, but still required assistance in all of these areas. According to the discharge plan, she was to receive 14 hours per day of personal care level 2 services, and "family will be able to provide additional hours of help during the day so that patient has 24/7 assist at home." Ongoing physical therapy (PT), occupational therapy (OT), and Speech-Language Pathology (SLP) therapies were recommended. Per the discharge summary, the required level of support and supervision on discharge is "intermittent physical assistance" and "24/7 supervision" for cognitive support.
A letter of support for this appeal was provided by the patient's son and reviewed in detail. The notes state that his mother wakes up every 90 minutes overnight asking for a drink or snack. Additionally, she forgets her disability and frequently tries to get up from her wheelchair. She has been getting dizzy and is at a high fall risk.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was noted to have moderately impaired cognition with decisions consistently poor/unsafe and requires cueing and supervision at all times. She is oriented times two and able to make her needs known, but not able to call 911 in an emergency. For her functional status, she requires total dependence on housework. She requires maximal assistance for meal preparation and managing medications. For ADLs, she requires maximal assistance for bathing, dressing her lower body, walking, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing her upper body, and bed mobility. She has total dependence on locomotion. She requires limited assistance for eating. Per the notes, she uses a wheelchair but depends on others for mobility, and "requires weight bearing assistance with transfer, bathing, and dressing. Member unable to prepare or reheat meals and need assistance with feeding. The patient lives alone in the community, and her son comes daily to check on her, he pre-pours medications into pill boxes and manages bills and medical appointments. Son reports that the member requires assistance during the night, she suffers from anxiety and insomnia." She is frequently incontinent of urine and uses incontinence products. She is occasionally incontinent of stool.
At issue is the medical necessity of personal care assistance services 24 hours per day 7 days per week in split shifts for a total of 168 hours per week medically necessary for this patient.

The requested health service/treatment of personal care assistance services 24 hours per day 7 days per week in split shifts for a total of 168 hours per week is not the medically optimal service for this patient. The health plan denied the coverage stating that her needs would be more appropriately met at a skilled nursing level of care. Regarding whether or not she is optimally managed in her home with 24-hour split shift care or if a nursing facility is more appropriate, the discharge notes state that she requires intermittent physical assistance but 24/7 cognitive support. Furthermore, the son's appeal states that needs overnight are for the prevention of falls and cognitive coach functions. Because personal care assistance is not allowable purely for the safety and security of the patient, these are not appropriate level 2 personal care functions. She, however, requires 24/7 cognitive support which would have to either be provided privately by the family (which is not an option) or at a skilled nursing facility. The discharge plan from the rehabilitation hospital indicated that she would be returning home with her personal care aide and 24/7 assistance from family for the gaps in care, but this was subsequently documented to be not available. The patient has 24-hour needs but right now those needs are of the skilled nursing type, not in the personal care realm. Personal care services are more appropriate for patients that require turning and positioning in bed or incontinence care overnight, neither of which was stated in this appeal as care gaps for this patient.