Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular/Other/Polyneuropathy
Treatment: Home Health Care/Personal Aide (PCA) 24 Hours (split-shift) per day, 7 days per week.
The health plan denied the requested Personal Aide (PCA) 24 Hours (split-shift) per day, 7 days per week as not medically necessary. The health plan's determination is overturned.

This is a case review for a female with a medical history notable for polyneuropathy and unsteady gait. The patient is approved for 12 hours per day, 7 days per week of personal care assistance services. The patient and her care team requested an increase to 24 hours per day, to 12 hour split shifts, 7 days per week.
The patient's physician provided a letter of support for this appeal. The letter states that the patient had a prior occipital stroke and has difficulties with ambulation due to polyneuropathy, unsteady gait, tremors, and vision impairment. The patient has chronic diarrhea due to C. diff (Clostridioides difficile) infection and has frequently recurrent urinary tract infections. The physician attests that she is unable to use the toilet and provide hygiene without assistance and requests additional care to prevent skin breakdown and further urinary tract infections.
Another physician provided a letter of support for this appeal. The specialist is caring for the patient for progressive memory loss. The letter notes that the patient has had a significant decline in her cognitive status with increasing frequency of confusion. She also has become agitated more often. She requires assistance to perform all activities of daily living and is at significant risk for falls if she does not receive assistance.
Nighttime caregiver logs were provided for review. The logs demonstrate that the patient wakes up every 2 to 4 hours overnight for personal care needs. These needs include diaper changes, assistance to the bathroom for bowel movements, and occasionally showering after episodes of stool incontinence.
A Uniform Assessment System was completed and was available for review. The assessment was conducted in person. The patient lives alone in her house. The patient was alert and oriented to person and place only, with disrupted short-term and procedural memory. For her instrumental activities of daily living, she requires total dependence for meal preparation, housework, finances, and shopping. She requires maximal assistance for medications, phone use, transportation, and equipment management. For her activities of daily living (ADL), she requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She was independent for bed mobility and eating. She is frequently incontinent of both stool and urine, and wears Pull-Ups for incontinence care.
At issue is the medical necessity for the requested Personal Aide (PCA) 24 hours (split-shift) per day, 7 days per week.

The health plan's determination of medical necessity is overturned, in whole.

The requested health service of Personal Aide (PCA) 24 hours (split-shift) per day, 7 days per week is medically necessary for this patient.
The patient has multiple medical problems and has had a progressive cognitive and functional decline, as described by the multiple physician letters. She also suffers from chronic diarrhea as a result of a C. difficile (Clostridioides difficile) infection and chemotherapy. She is dually incontinent and requires toileting and diaper changes throughout the day and night. Her personal care needs are continuous and unscheduled in nature, and continuous 24 hour care is medically necessary to meet her personal care needs. The nighttime caregiver logs demonstrate that a live-in aide would not be able to receive sufficient rest. Therefore, the request for 24 hour split-shift care is medically necessary and appropriate for the patient.