Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heart failure, hypertension, diabetes, and breast cancer
Treatment: Personal Care Assistant 24 Hours Per Day, 7 Days Per Week, split shift
The insurer denied the Personal Care Assistant 24 Hours Per Day, 7 Days Per Week, split shift
The denial is overturned.

The patient is a female. Her conditions include heart failure, hypertension, diabetes, and breast cancer, in remission.  She lives alone in an apartment.  Personal Care Assistant 24 hours per day, 7 days per week, split shift is being appealed. She has been approved for 12 hours per day, 7 days per week for a total of 84 hours per week.

The patient's daughter asked for an increase due to frailty, decreased ability to walk and continuous oxygen. She was diagnosed a few months ago with heart failure. UAS (Uniform Assessment System) evaluation shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, shopping, bathing, personal hygiene, dressing, walking, locomotion, and toileting; extensive assistance with managing finances and medications, phone use, and bed mobility; and independent with eating.  The patient cannot go to the bathroom by herself.  She cannot get out of the bed by herself.  Her DME (durable medical equipment) includes a rollator, shower chair, grab bar, raised toilet seat, PERS (personal emergency response system), and oxygen concentrator.  She is infrequently incontinent.  No falls in prior 90 days are documented.

An appeal letter notes the patient's condition has been severely exacerbated over the past couple months.  She has been hospitalized from a fall and is almost bedridden.  The letter notes that the patient requires frequent position changes, to keep skin dry to reduce risk of developing pressure ulcers.

Yes, the Personal Care Assistant 24 Hours Per Day, 7 Days Per Week, split shift 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. 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. Denial of Personal Care Assistant 24 hours per day, 7 days per week, split shift, is being appealed. She has been approved for 12 hours per day, 7 days per week for a total of 84 hours per week.

This patient has multiple chronic medical conditions, including oxygen dependence. She was hospitalized due to heart failure. UAS (Uniform Assessment System) evaluation performed shows the patient requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living) except eating. She has occasional incontinence. The patient's daughter notes the patient has decreased ability to walk and needs continuous oxygen. Appeal letter from her provider notes her condition has deteriorated after a fall. She is almost bedridden and requires frequent repositioning. Based on the provider's statement, the patient's ambulatory status has declined significantly. This, in addition to the need for frequent repositioning, supports the medical necessity for additional PCA (personal care assistance) hours. The approved PCA (personal care assistance) 84 hours per week is insufficient to meet this patient's needs for assistance with frequent repositioning. The proposed increase in PCA (personal care assistance) to a 24 hours per day is medically necessary.