Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, vertigo, frequent UTI (urinary tract infection), fractures
Treatment: Personal Care Assistance services for 24 hours (hrs) per day 7 days per week, spilt shift, for a total of 168 hrs per week
The insurer denied the Personal Care Assistance services for 24 hours (hrs) per day 7 days per week, spilt shift, for a total of 168 hrs per week.
The health plan's determination is overturned.

The patient is a female with a medical history notable for stress incontinence, osteoarthritis, frequent UTI's, coronary artery disease, and chronic pain. The patient was approved for 53 hours (hrs) per week of personal care assistance. The patient and her care team requested an increase to 24 hours per day (split-shift), 7 days per week (168 hours per week) and this request was partially denied by the health plan. They did approve an increase to 84 hours per week. The denial of 24-hour split-shift care is the subject under review.

The patient's daughter-in-law provided a letter of support for this review. The letter attests to her nighttime needs, stating that "she has to go to the bathroom 5 to 6 times at night and needs personal assistance to use the commode or change the diaper." The night time care logs by the patient's daughter in law detail personal care activities every 2 to 3 hours overnight, including frequent toileting and wet diaper changes. Her daughter in law is not able to provide continuous overnight support.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to have minimally impaired cognition and was capable of directing her own care although periods of forgetfulness were noted. From a functional standpoint, she requires maximal assistance for meal preparation, housework, shopping, finances, and transportation. She requires extensive assistance for stairs and medications. For her activities of daily living (ADL's), she requires maximal assistance for bathing, hygiene, dressing of her lower body and upper body, walking, locomotion, toilet transfers, toilet use, and bed mobility. She requires extensive assistance for eating. The notes state that she needs maximal assistance with transferring and completing her ADL's. "She can only tolerate bed baths now; she can no longer safely transfer to the bathroom. She needs to have 2 to 3 bed baths a day and clothing changes due to urinary incontinence." She is frequently incontinent of urine and is instructed to void every 2 hours to limit episodes of incontinence and UTI's. She uses pull ups overnight and has to wait until the morning for her aide to change them, which has resulted in UTI's. She also takes Furosemide for heart failure which worsens her urinary incontinence.

The patient is homebound and reliant on others for activities of daily living. She uses a wheelchair for locomotion. She fell in her home 6+ months prior to presentation which resulted in a wrist fracture. This fall occurred while she was attempting to transfer to the commode overnight without assistance. She was stuck laying on the floor until her PCA arrived the next morning. This was one of several instances of a fall and injury that the patient sustained within the past year.

The patient requires maximal assistance for all of her ADL's. She has frequent toileting needs throughout the day and night. Her care logs demonstrate that she has personal care needs overnight. Her prior fall and wrist fracture when attempting to transfer without assistance overnight is evidence that she has not been provided with sufficient support for her functional needs. She has frequent urinary tract infections and cannot be left alone overnight in soiled diapers.