Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence.
Treatment: personal care services.
The insurer denied Personal Care Services, Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week. 
The health plan's determination is overturned. 

The patient is a male with past medical history of Alzheimer's dementia, bowel incontinence, bladder incontinence, benign prostatic hyperplasia (BPH), history of pressure ulcer left heel, hypertension, and hypothyroidism who had been assigned personal case services (PCS). There was a request to increase PCS and the patient underwent a telephonic assessment tool that assessed the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, transportation, bathing, locomotion, and toilet use while maximum assistance with tasks of managing finances, managing medication, phone use, personal hygiene, bed mobility, and eating. Activities of walking and transfer toilet did not occur and were not given estimated assistance needed. Notes from the assessment noted the patient was severely impaired cognitively, was unable to walk, was wheelchair dependent, and required diaper change every 2 hours with skin care after toileting and repositioning every 2 hours to prevent ulcers.

Personal Care Services, Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week are medically necessary for this patient.
The patient had previously been approved for PCS hours 24 hours/day, live-in, 7 days/week with noted need for frequent diaper change, skin care, and turning and repositioning based on the assessment. There was documentation the patient had a prior left heel ulcer. The patient has full incontinence of bowel and bladder putting him at risk for skin breakdown, ulceration, and infection without prompt changing of diaper and skin care to the diaper area. The patient had past history of pressure ulcer putting him at high risk for a new pressure ulcer. The requested increase in PCS hours to split shift is not solely for safety and supervision but to assist the patient with safe completion of transfer toilet, toilet use, personal hygiene. The patient's assistance needs would not allow a PCS to obtain at least 5 hours of uninterrupted sleep. The current PCS hours and/or medical supplies and/or adaptive equipment are not sufficient to meet the patient's activities of daily living (ADL) / Instrumental activities of daily living (IADL) care needs. The insurer's justification to not cover 24 hour/day, split-shift services because the patient does not have a current pressure ulcer is not valid as turning and repositioning would be recommended even if this patient did not have a current pressure ulcer as to prevent new one (s) from occurring. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCS 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.