Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cerebrovascular Accident, Congestive Heart Failure.

Treatment: Personal Care Services 24 hours per day, 7 days per week (split shift).

The insurer denied coverage for Personal Care Services 24 hours per day, 7 days per week (split shift).

The denial is modified.

This elderly patient presented to the emergency due to a fall. The patient was admitted from the emergency room to hospital admission. The admission diagnoses included mitral valve insufficiency, paroxysmal atrial fibrillation, hypertension, acute on chronic congestive heart failure, pneumonia in the right lower lobe due to infectious organism, portal vein thrombosis, pulmonary congestion, heart failure with preserved ejection fraction, and hematoma. The assessment noted that the participant needs assistance with all functional mobilities. The participant was discharged several days later. 

The Uniform Assessment System (UAS) noted the patient was minimally impaired with cognitive skills for daily decision-making, had minimal fatigue, had psychiatric depression present (receiving active treatment), and that pain control was adequate by therapy regimen. For Instrumental Activities of Daily Living (IADLs), the patient required maximal assistance for meal prep, housework, and shopping. For Activities of Daily Living (ADLs), the patient required maximal assistance for personal hygiene extensive assistance and dressing the upper body, extensive assistance for dressing the lower body, and maximum assistance for locomotion, transfers, toileting, and bed mobility.  The patient was independent with eating as long as the set-up was provided.  

The Community Assessment noted that the patient requires non-weight-bearing assistance with upper body dressing and personal hygiene; significant weight-bearing assistance with lower body dressing and bathing; ambulation assistance with a rollator due to poor endurance; and minimal participation in cooking/cleaning. The patient also needs assistance opening medication bottles as well as medication reminders for compliance. The family is supportive and is available to assist as needed. 
The scope of the Personal Care Services (PCS) benefit includes continuous personal care services, which means the provision of uninterrupted care, by more than one person, for more than 16 hours per day for a patient who, because of the patient s medical condition and disabilities, requires total assistance with toileting, walking, transferring or feeding at times that cannot be predicted. Based on the participant's assessments, and medical documentation level of functioning is 35 hours per week; 5 hours per day/7 days a week is not sufficient to meet the patient's assisted care needs. 
The prior Hours Evaluation for Paraprofessional Support (HELPS) tool assessment recommended 40.5 hours a day. The documentation did not support unpredictable, frequent nighttime needs and that a care aide would be unable to get at least 5-8 hours of sleep at night, which would have supported possible split-shift care. However, the documentation supported a decline in status and the need for additional hours. An increase to 10 hours a day would be sufficient to meet the patient's needs as it could be used flexibly throughout the day. While personal care services 24 hours per day, 7 days per week (split-shift) are not medically necessary, 10 hours per day, 7 days per week is medically necessary.   

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

While the medical necessity for Personal Care Services 24 hours per day, 7 days per week (split shift) is not substantiated, the medical necessity of 10 hours per day, 7 days per week is substantiated.