Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Attack/non-STEMI (ST Elevation Myocardial Infarction) elevated myocardial infarction
Treatment: Home Health Care/Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift)
The health plan denied the requested Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) as not medically necessary. 
The health plan's determination is upheld.

This is a case review for a male with a medical history notable for dementia, incontinence, gait and mobility disorder, history of myocardial infarction, and deep vein thrombosis (DVT). The patient was receiving 56 hours per week of personal care services. The patient and his care team requested an increase to 24 hour per day split-shift care. 
A letter of medical necessity for this appeal was provided by the treating physician. The physician states that the patient is dependent on others for all activities of daily living, including for the use of durable medical equipment (DME) to help with his activities of daily living (ADLs). The letter states he has incontinence of both urine and stool. He requires prompting and cueing to initial tasks.
A letter of support for this appeal was provided by the patient's attorney and reviewed in detail.
Medical records were provided from a hospitalization for congestive heart failure exacerbation. The patient received diuresis and treatment for urinary retention. He was discharged home in stable condition.
Office visit notes and after visit summaries from several visits with the patient's cardiologist were provided for review. The patient was being treated for congestive heart failure and a non-ST elevation myocardial infarction (NSTEMI) with medical therapy.
Compared with a prior Uniform Assessment System (UAS) tool, the patient demonstrated worsening functioning in managing medications, hygiene, dressing upper body, bed mobility, and eating. A task tool associated with the most recent UAS recommended 52.33 hours per week to address the patient's personal care needs.
At issue is the medical necessity for the requested health service/treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift).

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

The requested health service/treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) does not have demonstrated medical necessity for this patient.

The health plan approved 24-hour live-in personal care services, so the question at hand is whether or not split-shift is more appropriate. A 24-hour live-in aide should have the expectation to get 5 hours of uninterrupted sleep per night. If a patient has personal care needs that preclude the ability to get this window of uninterrupted sleep, then split shift is more appropriate. In this case, there is no demonstrated medical need for personal care services with that frequency overnight. His attorney referenced the medical necessity letter from his physician stating that the patient has incontinence of both stool and urine, but this is not what was documented by the UAS, which was completed more recently than the physician letter. The UAS states that he has incontinence only when he cannot make it to the bathroom in time, and that this happens less than once a day. There was no mention of the need for diaper changes overnight, and he should be able to manage his fluid intake and medications to not require a bathroom break for a 5-hour period. There is no recommendation from his physician for turning and positioning and no history of a pressure ulcer. The patient has a history of wandering at night, but this is not a personal care task that would be covered by personal care services.