Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Mobility Issues
Treatment: Personal Care Services: 24 Hours a Day, 7 Days a Week (Split Shift) - Total of 168 Hours per Week
The insurer denied Personal Care Services: 24 Hours a Day, 7 Days a Week (Split Shift) - Total of 168 Hours per Week.
The health plan's determination is overturned in part.

This is a female patient with medical history notable for mobility issues. The patient is approved for 7 hours per day, 7 days per week (49 hours per week) of personal care services. The patient and her care team requested an increase to 24 hours per day, two 12-hour split-shifts, 7 days per week for a total of 168 hours per week. This request was denied by the health plan.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted at a skilled nursing facility where the patient was receiving short-term rehabilitation after a fall at home and anticipating discharge to her apartment where she lives alone. The patient was alert and oriented with periods of forgetfulness. She is able to direct her own care. For her Instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, and stairs. She requires maximal assistance for shopping. She requires extensive assistance for all other activities. For her activities of daily living (ADLs), the patient requires total dependence for locomotion. She requires maximal assistance for bathing, dressing, walking, toilet transfer, and toilet use. She requires extensive assistance for hygiene and bed mobility. She ambulates with a rollator walker with caregiver assistance and frequent breaks. She relies on a scooter for longer periods of ambulation. Her gait is slow and unsteady. She requires caregiver support for transfers including toileting. She is frequently incontinent of urine and stool and uses pull ups for incontinence care. There was no fall in the previous month; she fell at home when attempting to get out of bed and fractured her ankle which resulted in hospitalization and Skilled Nursing Facility (SNF) rehabilitation. At issue is the medical necessity of Personal Care Services: 24 Hours a Day, 7 Days a Week (Split Shift) - Total of 168 Hours per Week.

In part. The requested health service of Personal Care Services: 24 Hours a Day, 7 Days a Week (Split Shift) - Total of 168 Hours per Week has not been demonstrated to be medically necessary for this patient. However, Personal Care Services: 24 Hours a Day, 7 Days a Week (Live-in) is medically necessary for the patient.
The patient requires caregiver assistance for all ADLs and IADLs. She is not able to ambulate, transfer, toilet, or manage incontinence care on her own. Her care needs are expected to be continuous and unscheduled at the day and occasionally at night as well. Therefore, it is medically necessary that she receive 24 hour live-in personal care. Her fall when attempting to get out of bed without assistance is evidence of unmet personal care needs. Failure to provide for her needs could result in further injury, infection, and/or skin breakdown.
24 hour per day split-shift personal care has not been demonstrated to be medically necessary for the patient. Split-shift services are reserved for patients whose personal care needs would preclude a live-in personal care aide from receiving adequate rest at night, such as the need for frequent turning/repositioning to treat a pressure ulcer. There is no documentation provided that would demonstrate medical necessity for split-shift care.