Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid Arthritis, Systemic Lupus Erythematous

Treatment: 168 hours/week, 12 hours x 2 x 7 days-split shift consumer direct 1 client personal care aide

The insurer denied coverage for 168 hours/week, 12 hours x 2 x 7 days-split shift consumer direct 1 client personal care aide

The denial is upheld 

The patient is seeking coverage for 168 hours/week, 12 hours x 2 x 7 days-split shift consumer direct 1 client personal care aide.  It was stated that the patient wanted to be discharged to the community with services.  The patient was residing in a nursing home.  The patient was independent with cognitive skills.  The patient was self-directing and could make their needs known.  The patient was cooperative, calm, and pleasant during the assessment.  The patient required maximal assistance with meal preparation.  The patient was totally dependent for ordinary housework, managing finances, and shopping.  The patient required extensive assistance for managing finances and limited assistance for phone use.  The patient required extensive assistance for transportation, dressing of the lower body, transfer to the toilet, and with toilet use.  The patient required limited assistance with bed mobility and personal hygiene.  The patient needed assistance with meal preparation and cooking due to bilateral hand deformities related to rheumatoid arthritis.  The patient would need weightbearing assistance to transfer in and out of the shower with use of a shower chair/transfer bench.  The patient could self-propel a wheelchair.  The patient was infrequently incontinent of bladder and continent of bowel.  The patient reported that they would go to sleep between 11 PM and 12 AM and wake up between 9 AM to 10 AM.  No issues with sleep were reported.  There was a history of insomnia that was managed with Ambien.  The patient reported weakness and pain.

It was stated that the patient required split shift with 24-hour care when they returned home.  The patient was diagnosed with rheumatoid arthritis, systemic lupus erythematous, urinary retention, and thyroid disorder.  The patient had prior abdominal aortic aneurysm repair and recurrent urinary tract infections.  

Per the cited references, personal care services are the provision of some or total assistance with personal hygiene, dressing, and feeding and nutritional and environmental support.  The services must be essential to the maintenance of the patient's health and safety in their home, be ordered by physician or nurse practitioner, and be based on an assessment of the patient's needs for the service in accordance with guidelines.  Patients who require uninterrupted care by more than 1 personal care aide for more than 16 hours in a calendar day may be appropriate for 24-hour split shift services when a personal care aide is unable to obtain 5 hours daily of uninterrupted sleep during the 8-hour sleep schedule.  In this case, the patient was residing in a nursing home.  There was a goal to be discharged into the community with services.  The patient required extensive assistance for managing finances and limited assistance for phone use.  The patient required extensive assistance for transportation dressing of the lower body, transfer to the toilet, and with toilet use.  The patient required limited assistance with bed mobility and personal hygiene.  The patient needed assistance with meal preparation and cooking due to bilateral hand deformities related to rheumatoid arthritis.  There was a partial increase to 56 hours of personal care assistance services.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for 168 hours/weeks, 12 hours x 2 x 7 days - Split Shift; Consumer Direct, 1 Client Personal Care Aide is not substantiated.