Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility
Treatment: Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 24 Hours per Day (Split Shift)
The insurer denied Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 24 Hours per Day (Split Shift)
The health plan's determination is overturned.

This is a case review for a female with a medical history notable for heart failure, dementia, and incontinence. The patient and her care team requested Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) increase to 24 hours per day (split-shift).
The patient's child provided a letter of support for this appeal. The patient lives alone in an apartment. She previously lived with her granddaughter, who is no longer able to assist with personal care needs. However, in the absence of a personal care aide, all care responsibilities now fall to the letter-writing child. The letter states that the patient has to get up 3 to 4 times per night to use her commode. Therefore, she is requesting an increase to split-shift care to provide for the patient's overnight care needs. In a separate letter, the patient's child describes the personal care needs of the patient. These include assistance with bathing, dressing, walking, transfers, toileting, and incontinence care. She describes the overnight hours as particularly difficult due to the patient getting up at least three times overnight. The patient's child works full-time during the day and cannot work all night as a caregiver.
The patient's granddaughter provided a letter of support for this appeal. The letter states that, as a previous caregiver, she noted that the patient would typically wake up 3 to 5 times per night and require assistance with toileting or incontinence care. This severely limited the amount of rest that she was able to get overnight. She was no longer able to continue doing this, given that she works during the day.
Overnight care logs were provided for review. They describe that the patient requires assistance every one to three hours overnight with toileting and incontinence care. There were no 5-hour blocks of uninterrupted time in the overnight care shift.
A Uniform Assessment System (UAS)was completed via video teleconference. The patient's cognition was minimally impaired. She was disoriented to time. She is able to direct her own care. For her instrumental activities of daily living, the patient requires total dependence for meal preparation, housework, finances, and shopping. She requires maximal assistance for transportation and managing medications. For her activities of daily living, the patient requires maximal assistance for bathing and dressing lower body. She requires total dependence for toilet use. She requires extensive assistance for all other activities. The patient is frequently incontinent of urine and infrequently incontinent of stool. She requires assistance with changing diapers after episodes of incontinence. There was no pressure ulcer present.
Office visit notes were provided for review. They describe the extensive personal care needs that the patient requires, including significant overnight care needs.
The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 24 Hours per Day (Split Shift) is medically necessary for this patient.
The patient requires caregiver assistance for essentially all activities. This includes transfers, locomotion, toilet use, and managing episodes of incontinence care. The overnight care logs demonstrate that these activities are occurring on a continuous and unscheduled nature throughout any given 24-hour period. This provided documentation clearly establishes that she has personal care needs which occur throughout the day and night. There is not an adequate break in her care needs to allow sufficient rest for a live-in personal care aide. Therefore, the request for 24-hour split-shift care is medically necessary for the patient. Failure to address the patient's personal care needs could result in skin breakdown and/or infection.