Appeal type: Medical necessity
Decision: Overturned

Orthopedic/ Musculoskeletal
Home Health Care

Diagnosis: Primary Generalized Osteoarthritis, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Heart Failure, Stress Incontinence, Glaucoma, Visual Loss, Gout, Fatigue, Dementia without Behavioral Disturbance, Fecal Urgency
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split-Shift)
The insurer denied the home care/personal care. The health plan's determination is overturned.

The patient is a male with a medical history notable for dementia, incontinence, arthritis, heart failure, and visual loss. The patient was approved for 24 hour per day live-in personal care. The patient and his care team requested an increase to 24 hour per day (split-shift).

The patient's nurse practitioner provided a letter of support stating the patient requires maximal assistance with transfers. He has worsening dementia and requires supervision and re-orientation to daily activities. He is dually incontinent of urine and stool. He tries to get up multiple times at night to use the bathroom and is at risk for falls if unassisted. This has caused significant stress and loss of sleep to his current live-in personal care aide.

A Uniform Assessment System (UAS) was completed and was available for review. The patient lives with his spouse in a 3 bedroom apartment. He was alert and oriented to person only with confusion noted. He was not able to direct his own care. For his Instrumental activities of daily living (IADL), he requires total dependence or maximal assistance for all. For his activities of daily living (ADL), he requires total dependence for bathing, dressing lower body, walking, locomotion, and toilet use. He requires maximal assistance for hygiene and dressing upper body. He requires extensive assistance for bed mobility and eating. He is frequently incontinent of urine and stool. Compared to a prior UAS, he showed a decline in cognitive, functional, and continence status.

At issue is the medical necessity of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split-Shift).
The health plan's determination of medical necessity is overturned, in whole.

The requested health service of Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is medically necessary for this patient.

The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5 hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, the question at hand is whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.

The patient requires hands-on assistance for all aspects of care, including transfers, toileting, and bed mobility. The letters document that the patient has overnight care needs which are interrupting the sleep of his current live-in aide. His care needs are expected to be continuous and unscheduled throughout the day and night and preclude adequate rest for his live-in aide. Therefore, the requested increase to split-shift care is medically necessary and appropriate for the patient. Failure to provide proper overnight care could lead to skin breakdown and/or infection.