Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cirrhosis of the liver
Treatment:  Personal Care Aide 12 hours per day at night, 7 days a week
The insurer denied Personal Care Aide 12 hours per day at night, 7 days a week.
The determination is upheld.

This is a male patient with a medical history notable for cirrhosis of the liver. The patient is approved for 6 hours per day, 7 days per week of personal care assistance. The patient and his care team requested an increase to 12 hours per day at night, 7 days per week, and this request was denied by the health plan.
The patient's hospice social worker provided a letter of support for this appeal. The patient's condition has progressed, and he is now on hospice care with the goal of passing away at home. He lives with his wife who recently sprained her wrist and is no longer to assist with turning the patient. The patient requires total care for activities of daily living. They are requesting additional hours so that he can have overnight care 7 days a week.
Hospice nursing notes were provided for review. The patient has unspecified cirrhosis of the liver and was recently admitted to the hospital with shortness of breath and abdominal distention. He has large volume ascites with a pleural effusion. He is status post paracentesis and thoracentesis for over 10L (liters) of fluid. He is on supplemental oxygen by nasal cannula for shortness of breath. They indicate that the patient has a new wound, but further details were not provided. Stage 1 pressure ulcer of the bilateral heals had healed completely.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient was learned-oriented but forgetful. He needs reminders for activities of daily living. For his instrumental activities of daily living, the patient requires total dependence for meal preparation, housework, and shopping. He requires maximal assistance for transportation and finances. He requires extensive assistance for medications, phone use, and equipment management. For his activities of daily living, he requires maximal assistance for bathing, dressing lower body, locomotion, and toilet use. He requires extensive assistance for toilet transfer, personal hygiene, and dressing upper body. He requires limited assistance for bed mobility and eating. Uses 2L (liters) of oxygen by a nasal cannula for shortness of breath. He is frequently incontinent of urine, and he is continent of stool. There was no pressure ulcer present at the time of his evaluation. At issue is the medical necessity of Personal Care Aide 12 hours per day at night, 7 days a week.
The requested Personal Care Aide 12 hours per day at night, 7 days a week is not medically necessary for this patient.
There were no physician letters provided as part of this appeal. It is unclear which personal needs, if any, are not being met with 6 hours of overnight personal care. Continuous personal care overnight is usually reserved for patients that have continuous needs such as active treatment of a pressure ulcer. Nursing notes mention a new ulcer, but no detail was provided. He requires only limited assistance for turning and repositioning. There are no nighttime logs detailing the requirement of assistance for any other personal care tasks. Therefore, there is insufficient evidence that the requested increase to a 12-hour overnight personal care is medically necessary for the patient.