Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, pulmonary hypertension, osteoarthritis, CVAs (cerebrovascular accidents), glaucoma, spinal stenosis, diabetes, and hypertension
Treatment: Split-Shift Personal Care Worker (PCW) Services (two 12 hours split shift per day 7 days per week)
The insurer denied: Split-Shift Personal Care Worker (PCW) Services (two 12 hours split shift per day 7 days per week)
The denial is overturned

The patient is an elderly male. His medical conditions include congestive heart failure, pulmonary hypertension, osteoarthritis, CVAs (cerebrovascular accidents), glaucoma, spinal stenosis, diabetes, and hypertension. Denial of split-shift personal care worker (PCW) services, two 12 hours split shift per day 7 days per week, is being appealed. The health plan approved PCW (personal care worker) live-in, 7 days per week. Uniform Assessment System (UAS) evaluation performed seven months ago shows moderately impaired condition and functional status: total dependence with meal preparation, housework, managing finances and medications, shopping, and toilet use; maximal assistance with phone use, transportation, bathing, lower body dressing, and toilet transfer and extensive assistance with personal hygiene, upper body dressing, walking, locomotion, bed mobility and eating. The patient has bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed nine months ago, there has been a decline with managing finances and medications, bed mobility, and 
eating. An appeal letter notes that the patient requires total assistance with ADLs (activities of daily living) with frequency throughout nighttime hours that precludes the aide's ability to obtain 5 consecutive hours of sleep. There has been a decline in the patient's condition, including worsening of congestive heart failure and urinary incontinence. A 24-hour needs study shows need for toileting every 2 to 3 hours. A letter from the patient's provider notes that the patient's functional status has declined over the past 6 months. The patient has developed a pressure ulcer due to inadequate nighttime care. 

The Split-Shift Personal Care Worker (PCW) Services (two 12 hours split shift per day 7 days per week) 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. Denial of split-shift personal care worker (PCW) services (two 12 hours split shift per day 7 days per week), is being appealed. The health plan approved PCW (personal care worker) live-in, 7 days per week. This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed seven months ago showed the patient requires maximal assistance to total dependence with all ADLs (activities of daily living). He is incontinent of bladder. Compared to UAS (Uniform Assessment System) evaluation completed nine months ago, there has been a decline with managing finances and medications, bed mobility, and eating. The appeal statements support a decline in the 
patient's functioning and dependence with all ADLs (activities of daily living), and that the patient requires frequent assistance with toileting, transfers, and turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved PCW (personal care worker) live-in, 7 days per week is inadequate to meet the patient's continuous needs. The requested increase to PCW (personal care worker) services, two 12 hours split shift per day 7 days per week is medically necessary.