Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute on chronic congestive heart failure. 
Treatment: Increase Personal Care Services (PCS) to 24 hours a day, split shift (two 12-hour shifts), 7 days a week, as a nonmutual case, for a total of 168 hours. 
The insurer denied: Increase Personal Care Services (PCS) to 24 hours a day, split shift (two 12-hour shifts), 7 days a week, as a nonmutual case, for a total of 168 hours. 
The denial is overturned. 

This elderly male has multiple chronic conditions including acute on chronic congestive heart failure, kidney failure, anemia, metastatic colon cancer, and arthritis. The denial of 
personal care services (PCS) to 24 hours a day, split shift (two 12-hour shifts), 7 days a week as a nonmutual case, for a total of 168 hours is being appealed. The health plan approved 12 hours a day, 5 days a week (non-mutual), morning shift, for a total of 60 hours, and 12 hours a day, 5 days a week, and 24 hours a day, 2 days a week, evenings and weekend shift (mutual), for a total of 108 hours. A statement from the patient's provider notes the patient was hospitalized recently. His condition has progressed, and he is bedbound. He shares services with his wife, but this is inadequate for the patient's needs for assistance with activities of daily living. His daughter is unable to provided constant care. 
A statement from the daughter notes she is no longer able to provide care for her parents. Her father's condition has worsened since recent hospital stay and the patient is now bedbound. He needs assistance with activities of daily living. He now has bowel and bladder incontinence, and she is no longer able to assist with toileting. He needs more assistance with transfers. Due to weakness, he needs help sitting up in bed. He needs assistance with transporting daily cardiac readings. 

The proposed increase in personal care services (PCS) to 24 hours a day, split shift (two 12-hour shifts), 7 days a week, as a nonmutual case, for a total of 168 hours 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. This patient has multiple chronic conditions and was recently hospitalized. The denial of personal care services (PCS) to 24 hours a day, split shift (two 12-hour shifts), 7 days a week as a nonmutual case, for a total of 168 hours is being appealed. The health plan approved 12 hours a day, 5 days a week (non-mutual), morning shift, for a total of 60 hours, and 12 hours a day, 5 days a week, and 24 hours a day, 2 days a week, evening and weekend shift (mutual), for a total of 108 hours. The appeal statements indicate that the patient's functional status has declined since hospitalization, and he is now bedbound. He is incontinent of bowel and bladder, and he needs assistance with all activities of daily living. He does not have informal support. The appeal statements indicate medical necessity for an increase in personal care services because the mutual services with his wife are inadequate to meet his needs. The information provided supports a deterioration in the patient's functional status to now being bedbound and having continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed personal care aide services for a total of 168 hours per week, split shift, is medically necessary.