Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Atrial fibrillation, osteoarthritis, and cataracts.
Treatment:  Increase Personal Service To 24 Hours A Day, Split Shift (two 12 hours shifts per day) 7 Days A Week A  Total Of 168 Hours a Week.
The insurer denied the  Increase Personal Service To 24 Hours A Day, Split Shift (two 12 hours shifts per day) 7 Days A Week A  Total Of 168 Hours a Week.
The denial is overturned, in part. 

The patient is a female who has multiple medical conditions including atrial fibrillation, osteoarthritis, and cataracts. She lives alone. Denial of increase in personal care service (PCS) to 24 hours a day, split shift (two 12 hours shifts per day) 7 days a week a total of 168 hours a week, is being appealed. The health plan approved 84 hours/week.

The patient's Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medication, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting; and extensive assistance with bed mobility and eating. The patient has bowel and bladder incontinence. She had a fall and was found on the floor. She was hospitalized for several days.

A letter from the patient's provider notes that the patient has multiple medical problems, including severe vision and hearing deficits. She has severe arthritis affecting gait. The letter notes that the patient uses her commode during day and night and needs supervision.

The Increase in Personal Service To 24 Hours A Day, Split Shift (two 12 hours shifts per day) 7 Days A Week A Total Of 168 Hours a Week is medically necessary, in part.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient, in part.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions and is status post hospitalization after a recent fall. Denial of increase in PCS (personal care service) to 24 hours a day, split shift (two 12 hours shifts per day) 7 days a week a  total of 168 hours a week, is being appealed. The health plan approved 84 hours per week.

The patient's Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). She has bowel and bladder incontinence. There is an appeal letter noting that the patient has multiple chronic medical conditions and has both day and night time needs for supervision with toileting. This patient has significant impairment in physical functioning. However, the documents do not show that the patient has continuous needs. There is no evidence of a frequency of needs that would prevent an aide from obtaining five hours daily of uninterrupted sleep during the aide's shift. Based on the patient's functioning, the approved PCS (personal care service) 84 hours per week is inadequate to meet her needs for assistance with ADLs (activities of daily living) and personal care. The proposed PCS (personal care service) to 24 hours a day, split shift, is not appropriate. An increase in PCS (personal care service) to 24 hours per day, live in, is medically necessary.