Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pressure Ulcer, Bowel and Bladder Incontinence

Treatment: Personal Care Services (PCS), 24 hours per day, split shift (12 hours, 2 shifts per day) 7 days per week

The insurer denied coverage for Personal Care Services (PCS), 24 hours per day, split shift (12 hours, 2 shifts per day) 7 days per week

The denial is overturned

This case involves a patient with a subject of review for the coverage of Personal Care Services (PCS), 24 hours per day, split shift (12 hours, 2 shifts per day) 7 days per week. 

The member was seen for follow-up evaluation of a recurrent pressure ulcer. According to the records, the patient requires total assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient received sufficient hours of home health aide. A physical exam showed no respiratory distress, no swelling of the lower extremities, alertness, responding to names and simple questions, and skin breakdown around the buttock area without exudates. The patient was referred for a wound care evaluation and advised to return for follow-up and to continue the current medication regimen.

The patient was seen for follow-up on their health status. The patient is nonverbal, but  responds to name and verbal stimuli. The member has two home attendants who assist with all ADLs and IADLs. The patient had a recent follow-up with a psychiatrist, and their medications were kept at the same dose. No current skin breakdown is noted. The current medical management was effective, and it was advised to continue the present plan and medications.

In a letter of medical necessity, it states that the member is not able to participate in ADLs as they require complete assistance. The patient no longer sees to any aspect of their own daily care and requires care during the night. The patient needs repositioning because of excess sputum production as well as changes in the evening. Due to the patient not repositioning themselves, they are at risk of re-developing bed sores. The patient needs to be repositioned multiple times during the day and evening to avoid any further skin breakdown.

In the medical necessity review, the request to qualify for continuous personal care services was denied. The participant must require uninterrupted care by more than one personal care aide for more than 16 hours in a calendar day with tasks such as toileting, walking, transferring, turning, or positioning with such frequency that a live-in 24-hour personal care aide would not be able to obtain on a regular basis 5 hours of uninterrupted sleep during the 8-hour sleep period. According to the report, the member needs frequent assistance with personal care services during the night. In an appeal letter, it is stated the patient requires care during the night and needs to be changed and repositioned to avoid further skin breakdown.

The patient has bowel and urinary incontinence, history of pressure ulcer, and is unable to reposition themselves to avoid continuous pressure. This requires ongoing repositioning over a 24 hour period and cannot be provided by a live-in.  To ensure that there is always an awake home attendant available to care for the member, split shift (two twelve-hour shift of home attendants every day) would be appropriate and reasonable.  Therefore, the request for the coverage of personal care services, 24 hours per day, split shift (12 hours, 2 shifts per day), 7 days per week, is medically necessary, and the original denial decision is overturned.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Services, 24 hours per day, split shift (12 hours, 2 shifts per day) 7 days per week is substantiated.