Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Incontinence/Urinary/Bladder Control.
Treatment:  Personal Care Services (PCS) 24 hours a day, split shift (two 12-hour shifts), 7 days a week.

The health plan denied Personal Care Services (PCS) 24 hours a day, split shift (two 12-hour shifts), 7 days a week.  The determination is overturned.

The patient is a female with medical history notable for impaired cognition, coronary artery disease, pulmonary edema, atrial fibrillation, and hypertension. The patient is approved for 24 hours (hrs) per day, 7 days per week live-in (91 hours per week) of personal care services. The patient and her care team requested an increase to 24 hours per day split shift (2-12-hour shifts), 7 days per week, and this request was denied by the health plan.

The patient's physician provided a letter of support for this appeal. The letter states that the patient was admitted to a short-term rehabilitation facility. Prior to that admission, the patient was living alone in her apartment with her live-in personal care aide and doing well. However, she has had a significant medical and functional decline since that time. The physician reports that she has a history of frequent urinary tract infections (UTI) and requires frequent diaper checks and changes for her urinary and fecal incontinence; she also requires turning and repositioning to prevent pressure ulcer formation. The physician states that for the patient to be safely discharged from rehabilitation, she would require the additional requested hours. They also state that a live-in aide would be unlikely to get the required amount of sleep at night due to the patient's personal care needs.

A Uniform Assessment System (UAS) was available for review. The assessment was conducted in the patient's nursing home. The patient was alert and oriented to person, place, and sometimes time; she was forgetful but self-directing. For her instrumental activities of daily living (IADL), she required total dependence for meal preparation, housework, stairs, shopping, and transportation. She required extensive assistance for finances and medications. For her activities of daily living (ADL), she required total dependence for walking, locomotion, and toilet transfer. She required maximal assistance for bathing, dressing her lower body, and toilet use. She required extensive assistance for hygiene, dressing upper body, bed mobility, and eating. She was frequently incontinent of urine and continent of stool.

At issue is the medical necessity of Personal Care Services (PCS) 24 hrs a day, split shift (two 12-hour shifts), 7 days a week.

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

The requested health service/treatment of Personal Care Services (PCS) 24 hrs a day, split shift (two 12-hour shifts), 7 days a week is medically necessary for this patient.
The patient's UAS demonstrates that she needs extensive assistance or greater for all ADL's. She requires total dependence for transfers and toileting. Her condition has apparently worsened as reflected by the letter of medical necessity from the requesting physician, and her true needs are now even greater. She is now incontinent of urine and stool and needs frequent checking as she cannot direct her own incontinence care. She also requires assistance with repositioning. Her personal care needs can be expected to be continuous and unscheduled throughout the day and night, and thus 2-12-hour split shift personal care is medically necessary and appropriate for the patient. Failure to provide for her around the clock personal care needs could result in skin breakdown and/or recurrent infection.