Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, osteoarthritis, status post knee replacement, sacral wound, weakness, and history of falling.
Treatment: Increase Personal Care Services to 168 Hours Per Week (split shift).

The insurer denied the Increase Personal Care Services to 168 Hours Per Week (split shift).  The denial is overturned.

The patient is a female. Her conditions include Alzheimer's disease, osteoarthritis, status post knee replacement, sacral wound, weakness, and history of falling. She is currently in a skilled nursing facility. Denial of increase personal care services (PCS) to 168 hours per week, split shift, is being appealed. The plan approved PCS (personal care service) 51 hours per week.

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances, shopping, transportation, bathing, lower body dressing, locomotion, walking, and toileting; extensive assistance with managing medications, phone use, personal hygiene upper body dressing, bed mobility, and eating. She is frequently incontinent of urine. She ambulates short distances with a walker. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline with bathing, personal hygiene, dressing, walking, locomotion, toileting, bed mobility, and eating.

A statement notes the patient's condition has declined over past 90 days. She requires assistance with all ADLs (activities of daily living) during day and overnight and the patient has unscheduled needs. The patient's PCP (primary care provider) notes the patient has chronic condition and is homebound/bedbound. She needs home care throughout the day and night. She needs assistance with ADLs (activities of daily living), including turning and repositioning every 2 hours. A letter from the patient's daughter notes she is unable to provide care and requests split shift care.

Yes, the requested Increase Personal Care Services To 168 Hours Per Week (split shift) is 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 services (PCS) to 168 hours per week, split shift, is being appealed. The plan approved PCS (personal care service) 51 hours per week.

This patient has multiple chronic conditions and has limited mobility. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). She is incontinent of bladder and has a sacral ulcer. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline with bathing, personal hygiene, dressing, walking, locomotion, toileting, bed mobility, and eating. Appeal statements indicate the patient's condition has deteriorated, and she requires care throughout day and night, including turning and repositioning every two hours. This patient has continuous needs, including frequent turning/repositioning that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved PCS (personal care service) 51 hours per week is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The requested PCS (personal care service) 168 hours per week, split shift, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.  The requested health service is medically necessary.