Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence/Urinary/Bladder Control
Treatmement: Increase in personal care aide hours to 7 days a week 2-12 hrs a day (split shift)
The health plan denied the increase in personal care aid hours to 7 days a week 2-12 hrs a day (split shift). 
The health plan's determination is overturned.

The patient is a female with medical history notable for dementia, congestive heart failure, urinary and fecal incontinence, nonhealing leg wounds, and pressure ulcer of the sacrum. The patient is approved for live-in personal care aide 7 days per week.

A letter of medical necessity for this appeal was provided by the treating physician. The letter states that the patient has had a rapid cognitive, physical, and functional decline. She requires human assistance for all activities of daily living (ADL). She has multiple day and nighttime soiled diaper changes. The physician recommends turning and repositioning in bed every two hours throughout the day and night.

Home nursing notes were provided for review. The patient has a non-healing chronic ulcer on both the right and left knee. The wound is being cleaned and dressed by a nurse in appropriate intervals. She has chronic lower extremity edema due to congestive heart failure. She has a stage 2 pressure ulcer of the sacrum. Local care for the wound was recommended, as well as the importance of not leaving soiled diapers on the patient following episodes of incontinence.

The most recent Uniform Assessment System (UAS) showed new onset of moderately impaired cognition. From a functional standpoint, she requires total dependence for housework, stairs, and shopping. She requires maximal assistance for meal preparation, managing medications and managing finances. For her ADL's, she requires total dependence for dressing lower body and locomotion. She is no longer able to walk. She has been sleeping in a recliner because it is impossible to transfer to the commode from her bed. She requires maximal assistance for bathing, hygiene, dressing upper body, toilet transfer, toilet use, and bed mobility. She showed a functional decline across nearly all domains when compared with the assessment from 2 months prior. She is frequently incontinent of urine and infrequently incontinent of stool.

At issue is the medical necessity of the requested health service/treatment of increase in personal care aide hours 7 days a week, 12 hours (hrs) a day to 7 days a week 2-12 hrs a day (split shift).

The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of increase in personal care aide hours 7 days a week, 12 hrs a day to 7 days a week 2-12 hrs a day (split shift) is medically necessary for this patient.

The patient has a sacral pressure ulcer and incontinence of feces and urine. She is unable to change her own diapers. She is unable to turn and reposition in bed without human assistance. She cannot be left alone for 5 or more hours overnight to allow a live in aide to sleep. She requires prompt changing of soiled diapers as well as turning/repositioning every 2 hours to promote healing of her pressure ulcer. Failure to provide for these personal care needs could lead to worsening of her ulcer and/or infection.