Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central Nervous System/Neuromuscular Disorder.
Treatment:  Personal Care Services hours increase to 24 hours/day 7 days/week (Split Shift). 

The insurer denied increase in personal care services hours to 24 hours/day 7days/week (Split Shift).  The denial is overturned in whole.

The patient is a female with past medical history of Alzheimer's dementia, depression, diabetes mellitus type 2, frequent falls, hyperlipidemia, hypertension, hypothyroidism, unilateral blindness, overflow incontinence, coronary artery disease and bed bound status, who had been hospitalized with subsequent skilled nursing facility stay, until she was transferred to home.

The health plan denied the request to increase PCA services to 24 hours/day, split-shift, 7 days/week.  This determination letter stated the patient's PCA hours were appropriate to meet her needs.  It stated, "you use a manual wheelchair to move about your environment," and PCA service time is not provided for safety and supervision.  The patient's PCP provided another letter noting the patient has been bed bound since her hospitalization, and the patient cannot turn herself in bed due to physical and cognitive impairments, and it is standard of care to be turned and repositioned every two hours.  The patient cannot rise from the bed and must be toileted in the bed, which also puts her at risk for infection and skin breakdown with recommendation for 24-hour home care.  The patient's health care advocate provided a letter reiterating the PCP's recommendation for nighttime assistance with turning, positioning and toileting and that the overlay mattress was not a substitute for the need to reposition the patient every 2 hours.

The requested personal care services: 24 hours per day, 7 days per week (split shift) is medically necessary for this patient.  The patient had a prolonged skill nursing facility stay following a hospitalization, and the initial assessment tool performed while she was still in Skilled Nursing Facility (SNF) underestimated her need for assistance.  The patient's assistance needs for tasks of toilet use and bed mobility were underestimated.  The patient was bedbound with the need for Hoyer lift for transfers, which when home required more than one person to perform.  The patient was then in the hospital bed for longer periods of time each day, putting her at risk for skin breakdown and infection.  The patient's PCP indicated it was necessary for the patient to be turned and repositioned every 2 hours day and night to prevent skin breakdown and infection.  The patient is not able to use the toilet and had toilet cares while lying in the hospital bed.  The patient does not have an informal helper.  The patient's PCA service hours are not solely for supervision and safety but to assist the patient with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) through day and night, some of which are unscheduled needs.  Due to the level of assistance the patient needs, this would mean a personal care aide would not be able to obtain 5 hours of uninterrupted sleep; therefore, split-shift services would be necessary.