Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CAD (coronary artery disease), status post femur fracture, spinal stenosis, osteoarthritis, morbid obesity, muscle weakness, and CKD (chronic kidney disease). 
Treatment: Increase Personal Care Assistance From 58 Hours Per Week To 24 Hours Per Day, 7 Days Per Week (split-shift), total 168 Hours Per Week. 

The insurer denied the Increase Personal Care Assistance From 58 Hours Per Week To 24 Hours Per Day, 7 Days Per Week (split-shift), total 168 Hours Per Week. 
The denial is upheld. 

The patient is a female. Her conditions include CAD (coronary artery disease), status post femur fracture, spinal stenosis, osteoarthritis, morbid obesity, muscle weakness, and CKD (chronic kidney disease). The member is in rehab for her femur fracture but lives alone in the community.  Denial of increase Personal Care Assistance from 58 hours per week to 24 hours per day, 7 days per week, split-shift, total 168 hours per week, is being appealed. 

UAS (Uniform Assessment System) evaluation completed shows the patient has modified Independent cognition and functional status: total dependence with meal preparation, housework, managing finances and medications; maximal assistance with shopping, transportation, bathing, lower body dressing, bed mobility, and toileting; extensive assistance with personal hygiene, upper body dressing; and Independent with eating. She uses a wheelchair and scooter for locomotion. She is currently wheelchair-bound. She is non-weight bearing on her legs. She is frequently incontinent of bowel and bladder. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline with managing finances and medications, bathing, lower body dressing, personal hygiene, toileting and bed mobility. 

An appeal statement is requesting additional hours due to needs for assistance with ADLs (activities of daily living) as accounted for in the UAS (Uniform Assessment System) evaluation, and unscheduled needs of transferring, toileting, and walking. The appeal notes that the patient needs to be turned and repositioned due to immobility. 

No, the increase in personal care assistance to 24 hours per day, split shift, is not 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 Personal Care Assistance from 58 hours per week to 24 hours per day, 7 days per week, split-shift, total 168 hours per week, is being appealed. 

This patient has multiple chronic conditions and is status post recent femur fracture and is wheelchair-bound. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living), except eating. She has frequent bowel and bladder incontinence. She is non-weight-bearing and requires assistance with turning/repositioning. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a deterioration with managing finances and medications, bathing, lower body dressing, personal hygiene, toileting and bed mobility. 

This patient has continuous needs and has a significant decline in functioning over one month. However, this is the result of the recent femur fracture, and is expected to be short-term. The patient should regain physical functioning with ongoing skilled home care.  The approved PCA (personal care assistance) 58 hours per week is sufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. Skilled home services should be utilized to meet additional needs/rehab, as asserted by the health plan.  The proposed 24 hours per day, 7 days per week, split-shift, total 168 hours per week is not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.