Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory System. 
Treatment: Home Health Care. 
The insurer denied increase in services to 24 hour split shift. 
The denial is upheld in whole.

The patient is a female with a past medical history significant for coronary artery disease, congestive heart failure, osteoarthritis, knee pain, neck pain, diabetes mellitus with neuropathy, dementia, hypertension, and urinary incontinence. This review is for the medical necessity of home care/personal care level 2 personal care services increased to 24 hours per day split shift. The patient is currently receiving 24-hour care live-in. Increase in services was denied based upon lack of medical necessity.

The health plan's determination is upheld.

The requested health service is not medically necessary for this patient.
Appropriate care can be provided with 24 hour live-in services. 
Uniform Assessment System (UAS) State of New York was reviewed. A letter of appeal by her physician was reviewed.
The patient has multiple medical problems including dementia, heart disease and diabetes. She is dependent for all of her Instrumental activities of daily living (IADLs)s and activities of daily living (ADLs). The patient is bedbound and requires assistance with transfers and is not ambulatory. She is incontinent of urine with no control and occasionally incontinent of feces.
Services being provided by the live-in aide include all of the patient's ADLs, IADLs including administration of pre-poured medication.
The documentation provided including the UAS, and physician notes and appeal letter failed to demonstrate medical need above and beyond what a 24-hour live-in aide could provide. There is no notation of why the patient would need more care hours and that the aide could not get proper rest defined as at least 5 hours of interrupted sleep. There is no specific need noted that would require the aide to be awake through the night such as frequent turning for decubitus ulcers. On review of the literature the following is noted in regard to prevention and management of pressure ulcers from Guidelines from the National Institutes of Health (NIH) published in England. The literature states: "Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every 6 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed."
"The results were inconclusive for other frequencies of repositioning however the Guideline Development Group (GDG) felt that any patients who have the chance of developing a pressure ulcer should be turned at least every 6 hours. The evidence was extrapolated for patients in hospital populations to those in the community as the outcome of reducing pressure ulcer development should be the same and that the benefits of repositioning was important enough to be extended to this population."
As concluded from the medical record and the letter from the provider the patient does not have an active pressure ulcer, even grade I , that is being treated.  Therefore, guidelines for this patient's situation turning at least every 6 hours is recommended which is also in the scope of the care being considered.   Additional services for safety monitoring is not considered medically necessary.