Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, osteoarthritis, stroke, insomnia, Alzheimer's disease, syncope, and urinary incontinence
Treatment: Increase home/personal care level 2 service to 24 hours/day (split shift)
The insurer denied the increase in home/personal care level 2 service to 24 hours/day (split shift).
The denial is overturned.

The patient is an elderly female. Her medical conditions include hypertension, osteoarthritis, stroke, insomnia, Alzheimer's disease, syncope, and urinary incontinence. She was admitted to a skilled nursing facility after hospitalization and a fall 3 months ago that resulted in a subdural hematoma. She fell when trying to get out of the bed and go to the bathroom. She lives alone. Denial of an increase in home/personal care level 2 service to 24 hours/day (split shift) is being appealed. The health plan approved 24 hours/day (live-in). The patient's Uniform Assessment System (UAS) evaluation completed 3 months ago shows severely impaired cognition and functional status requires maximal assistance to total dependence with all activities of daily living (ADLs), except limited assistance with bed mobility and supervision with eating. She has frequent bowel and bladder incontinence. There has been a significant decline in her functional status compared to UAS evaluation completed earlier this year. A letter from the patient's daughter reports that the patient is a fall risk. She gets up multiple times during the night to use the bathroom, affecting the home health aide's ability to get proper sleep. There is a statement of aides complaining of inability to get proper sleep during the night because the patient gets up to go the bathroom during the night. A letter from a nurse practitioner notes that the patient needs increased hours to prevent further falls and injuries.

The requested increase in home/personal care level 2 service to 24 hours/day (split shift) is medically necessary. 

Denial of an increase in home/personal care level 2 service to 24 hours/day (split shift) is being appealed. The health plan approved 24 hours/day (live-in). The health plan denied the requested hours based on the UAS evaluation. This patient has multiple chronic conditions, including a recent subdural hematoma after a nighttime fall at home. She lives alone and does not have informal support. The UAS evaluation completed 3 months ago shows she requires maximal assistance to total dependence with all ADLs, except limited assistance with bed mobility and supervision with eating. She has frequent bowel and bladder incontinence. There has been a significant decline in her functional status compared to UAS evaluation completed earlier this year. The appeal statements support that the patient needs increased hours for assistance with ADLs that include frequent toileting during the nighttime. This includes information from home care aides regarding the inability to get uninterrupted sleep. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The currently approved personal care services 24 hours/day (live-in) is inadequate to meet this patient's needs for assistance with ADLs. The requested increase to 24 hours/day (split shift), is medically necessary.