Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, epilepsy, hypertension, foot drop, arthritis, osteoporosis, chronic falls, chronic urinary tract infections, and vertigo
Treatment: Increase Personal Care Service to 24 Hours per Day, Split Shift (Two 12-hour Shifts Per Day), 7 Days a Week for a Total of 168 Hours per Week
The insurer denied Increase in Personal Care Service to 24 Hours per Day, Split Shift (Two 12-hour Shifts Per Day, 7 Days a Week for a Total of 168 Hours per Week.
The denial is overturned.

The patient is an elderly female. Her medical conditions include stroke, epilepsy, hypertension, foot drop, arthritis, osteoporosis, chronic falls, chronic urinary tract infections, and vertigo. She lives alone. Denial of increase personal care service to 24 hours per day, split shift (two 12-hour shifts per day, 7 days per week for a total of 168 hours per week) is being appealed. The health plan approved PCS (personal care service) 7 hours per day, 5 days per week, and 6 hours per day, 2 days per week, for a total of 47 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 2 months ago shows modified independent cognition and functional status of extensive to maximal assistance with all ADLs (activities of daily living), except limited assistance with bed mobility and independent with eating. The patient has frequent bladder incontinence. A letter from the patient's provider reports the patient's condition has deteriorated. The patient is unable to ambulate without assistance and is at risk of falling. Trigger finger and carpal tunnel syndrome affect her ability to hold objects and feed herself. She requires hands-on assistance with prompting with ADLs (activities of daily living). Her current hours result in her being left in a solid diaper until the next day. She has no informal support. Continuous home care is recommended due to unscheduled need for assistance. A letter from the patient's daughter reports the patient has debilitating pain and stiffness as well as drop foot. She needs assistance with ambulation and ADLs (activities of daily living). When the aide leaves, the patient remains in bed until the next morning. Due to multiple medical 
conditions, she is unable to perform daily tasks. Nighttime logs primarily show assistance from bed to bathroom every one to two hours.

The requested Increase Personal Care Service to 24 Hours per Day, Split Shift (Two 12-hour Shifts Per Day), 7 Days a Week for a Total of 168 Hours per Week is medically necessary.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. 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 service to 24 hours per day, split shift (two 12-hour shifts per day), 7 days per week for a total of 168 hours per week is being appealed. The health plan approved PCS (personal care service) 7 hours per day, 5 days per week, and 6 hours per day, 2 days per week, for a total of 47 hours per week. The health plan denied the increase, noting that the aides can be split to meet the patient's morning and evening needs. This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed 2 months ago shows she requires extensive to maximal assistance with all ADLs (activities of daily living), except limited assistance with bed mobility and independent with eating. She has frequent bladder incontinence. The appeal statements support that there has been a deterioration in the patient's functional status. She requires assistance with ambulation due foot drop as well as ADLs (activities of daily living). She does not have informal support and is left in the bed at the end of the aide's shift until the next day. Nighttime logs primarily support the need for frequent assistance, supporting assistance from bed to bathroom every one to two hours. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. In addition, splitting currently approved hours is inadequate to meet the patient's transfer and toileting needs. The currently approved PCS (personal care service) hours are insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase of PCS (personal care service) to 24 hours per day, split shift (two 12-hour shifts per day), 7 days per week for a total of 168 hours per week is medically necessary.