Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, Stroke
Treatment: 24 hours per day, 7 days per week (2 shifts of 12 hours of aide services) of Level 2 Personal Care Assistance Services.
The insurer denied 24 hours per day, 7 days per week (2 shifts of 12 hours of aide services) of Level 2 Personal Care Assistance Services.
The determination is upheld.

This is a male patient with a medical history notable for hypertension. The patient was approved for 42 hours per week of personal care assistance. The patient and his care team requested an increase to 24-Hour per day, two 12-hour split-shifts, 7 days per week for a total of 168 hours per week. This request was partially denied by the health plan, who did approve an increase to 24 hour live-in personal care, 7 days per week. 
The physician at the patient's rehabilitation center provided a letter of support for this appeal. The letter states that the patient requires assistance with dressing, toileting, and transfers. He is on multiple medications for hypertension which cause him to have frequent urinary discomfort and the need for him to toilet overnight and drink water at unspecified times during 24-hour periods. The physician therefore recommends 24-hour care for the patient on discharge to allow his personal care needs to be met.
A Uniform Assessment System was completed. For his activities of daily living, the patient requires maximal assistance for bathing, dressing lower body, locomotion, toilet transfer, and toilet use. He requires extensive assistance for hygiene and dressing upper body. He requires limited assistance for bed mobility. The assessment notes that the staff at the skilled nursing facility usually put the patient to bed between 9:30 and 10:00 PM, and he subsequently requires a diaper change at 7:00 AM. when he wakes up in the morning. He is frequently incontinent of urine and uses 3 to 4 diapers per day. He would also use a condom catheter. He is continent of stool. 
The requested health service of 24 hours per day, 7 days per week (2 shifts of 12 hours of aide services) of Level 2 Personal Care Assistance has not been clearly demonstrated to be 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, there is a question as to 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 personal care assistance with all activities of daily living. His personal care need frequency overnight has not been clearly demonstrated to be of such frequency that would preclude a living personal care aide from receiving adequate rest. He does have some episodes of incontinence, but the skilled nursing facility notes do not describe the need for frequent changes overnight. There were no nighttime care logs provided for review. The patient has no evidence of pressure ulcers which would require frequent turning and repositioning in bed. Therefore, the requested service has not been clearly demonstrated to be medically necessary for the patient.