Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes, osteoarthritis, hyperlipidemia, cystocele, urge incontinence, and syncope. 
Treatment: Home Care / Personal Care HHC - Level II Personal Care Services, per 15 Minutes Increase to 24 Hour(s) per Day (Split Shift). 

The insurer denied the Home Care / Personal Care HHC - Level II Personal Care Services, per 15 Minutes Increase to 24 Hour(s) per Day (Split Shift). 

The denial is overturned. 

The patient is a female. She has diagnoses including hypertension, diabetes, osteoarthritis, hyperlipidemia, cystocele, urge incontinence, and syncope. This is an appeal for denial of PCS (personal care service) 24 hours per day, split shift. She was approved for a partial increase from 36 to 42 hours per week. 

UAS (Uniform Assessment System) evaluation performed previously shows modified independent cognition and functional status: total dependence with meal preparation and housework; maximal assistance with shopping; extensive assistance with managing medications, stairs, bathing, and lower body dressing; limited assistance with walking, locomotion, and toilet transfer; and independent with personal hygiene, toilet use, bed mobility, and eating. She is frequently incontinent of bladder. She was hospitalized with altered mental status and status post fall. UAS (Uniform Assessment System) evaluation performed most recently shows changes to include: minimally impaired cognition, total dependence with shopping; maximal assistance with transportation, bathing, lower body dressing, walking, locomotion, and toileting; and limited assistance with personal hygiene. She has been bedbound since hospitalization. She has a wheelchair and scooter for locomotion. Her husband cooks, and her daughter shops. 

The appeal request notes that after the phone assessment, the patient was hospitalized from a fall and has been in bed and unable to walk. It notes she needs supervision and total help with ADLs (activities of daily living). 

The daughter has provided a log showing assistance every 2-3 hours during the night to include changing diaper and repositioning. 

Yes, the increase in personal care services to 24 hours/day, split shift, is medically necessary. 

The requested health service is consistent with generally accepted standards of medical practice. 

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  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 provider five hours daily of uninterrupted sleep during the aide's shift. 

This patient has multiple chronic conditions.  She was recently hospitalized with altered mental status and a fall.  She has been bedbound since discharge.  The patient is appealing denial for PCS (personal care service) 24 hours per day, split shift.  She was approved for PCS (personal care service) 42 hours per week.  UAS (Uniform Assessment System) evaluation performed most recently shows significant decline from UAS (Uniform Assessment System) evaluation performed three months prior.  The patient's cognitive and functional status have declined, and she requires assistance with all ADLs (activities of daily living) except bed mobility and eating.  She is incontinent of urine.  She has assistance of her husband to cook and daughter to shop.  The appeal notes that since the fall, the patient is unable to walk and needs total help.  This patient has significant functional limitations with rapid progression. 

The patient's daughter has provided a log showing assistance every two to three hours throughout the night, with diapering and repositioning.  This patient has continuous needs that cannot be met with PCS (personal care service) 42 hours per week.  The requested continuous PCS (personal care service), 24 hours per day, split shift are appropriate and medically necessary to meet this patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living), as noted above.