Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, osteoarthritis, and incontinence. 
Treatment: Personal Care Assistance Services, Level II: Two 12 Hours Split Shifts per Day, 7 Days per Week for a Total of 168 Hours per Week. 
The insurer denied: Personal Care Assistance Services, Level II: Two 12 Hours Split Shifts per Day, 7 Days per Week for a Total of 168 Hours per Week. 
The denial is overturned.

This elderly female patient has conditions including heart failure, obesity, pulmonary hypertension, osteoarthritis, and incontinence. She lives alone. The denial of personal care assistance services, two 12 hours split shifts per day, 7 days per week, for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week. Uniform Assessment System (UAS) evaluation completed last month shows the patient has minimally impaired cognition and functional status: total dependence with meal preparation, housework, shopping, transportation, bathing, lower body dressing, and locomotion; maximal assistance with managing finances and medications, personal hygiene, upper body dressing, and toileting; and extensive assistance with bed mobility and eating. A letter from the patient's caseworker, notes the patient's activities of daily living (ADL) have declined compared to 90 days ago. The patient requires assistance with all activities of daily living. She requires frequent change of diapers due to incontinence. A letter from the patient's physician notes the patient urinates frequently due to treatment with diuretics. She has chronic cellulitis and frequent urinary tract infection (UTIs). She needs to be washed and dried after urinating at night. She has a history of multiple falls. Her functional and mental status have deteriorated. A letter from the patient's daughter notes the patient wakes up frequently throughout the night. Her skin is easily irritated, and she gets a rash in wet diapers. Night logs show the patient receiving assistance with toileting every one to two hours. 

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. The denial of personal care assistance services, two 12 hours split shifts per day, 7 days per week, for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week. Uniform Assessment System (UAS) evaluation completed last month shows the patient requires extensive assistance to total dependence with all activities of daily living. She is incontinent of bowel and bladder. The appeal statements note that the patient's functional status has deteriorated, and she is dependent with all activities of daily living. The night logs support that the patient requires frequent assistance with toileting and transfers. This patient's needs cannot be met with the approved personal care assistance services of 84 hours per week. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The personal care assistance services, two 12 hours split shifts per day, 7 days per week, for a total of 168 hours per week is medically necessary.