Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral infarction. 
Treatment: Increase Personal Care Assistance From 42 Hours Per Week To 24 Hours Per Day, 7 Days Per Week, split shift. 

The insurer denied the Increase Personal Care Assistance From 42 Hours Per Week To 24 Hours Per Day, 7 Days Per Week, split shift. 

The denial is overturned. 

The patient is a female. Her medical conditions include cerebral infarction. She is bedbound, and she has no decision-making capabilities. Denial of increase in Personal Care Assistance from 42 hours per week to 24 hours per day, 7 days per week, split shift is being appealed. 

UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, bathing, walking, toilet transfer, and locomotion; maximal assistance with managing medications, phone use, personal hygiene, dressing, toilet use, and bed mobility; and extensive assistance with eating. 

A letter from the patient's provider notes the patient is terminally ill and enrolled in hospice and palliative care. The letter recommends increase in hours to better manage the patient's care, comfort and safety. The letter notes the patient is bedbound and increasingly confused. 

A letter from the patient's social worker notes the patient requires total assistance with ADLs (activities of daily living) and lacks family support. The letter notes the patient is totally dependent with ADLs (activities of daily living). 

Visit Note from hospice shows the patient has slurred speech, weakness and needs one-person assistance at all times. The patient needs to be turned/repositioned every two hours and frequently transferred out of bed to wheelchair. The patient is incontinent of bowel and bladder. 

Yes, the requested Increase Personal Care Assistance From 42 Hours Per Week To 24 Hours Per Day, 7 Days Per Week, split shift, is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase in Personal Care Assistance from 42 hours per week to 24 hours per day, 7 days per week, split shift, is being appealed. 

The patient is terminally ill, bedbound and does not have capacity for decision making. Per UAS (Uniform Assessment System) evaluation completed, the patient requires assistance with all ADLs (activities of daily living). She has bowel and bladder incontinence. Appeal letters note the patient is increasingly confused and totally dependent with all ADLs (activities of daily living). The note from hospice care shows the patient requires turning/repositioning every 2 hours. This patient has progressive cognitive and physical impairments. She requires significant assistance with ADLs (activities of daily living) and frequent turning/repositioning. The approved 42 hours per week is inadequate to meet the patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). The proposed increase in PCA (personal care assistance) to 24 hours per day, 7 days per week, split shift is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.