Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive Decline
Treatment: Home care/personal care HHC- level 2 personal care services per 15 minutes increase to 24 hours per day (split shift).
The insurer denied home care/personal care HHC- level 2 personal care services per 15 minutes increase to 24 hours per day (split shift).
The determination is overturned.


The patient has a medical history notable for incontinence, tremors, type 2 diabetes, coronary artery disease, age related cognitive decline, and osteoporosis. The patient is approved for 84 hours per week of personal care services (consumer directed). The patient and her daughter requested an increase to 24 hour per day split-shift (168 hours per week), and this request was denied by the health plan.
A letter of support for this appeal was provided by a patient advocate. The letter describes that the patient had been living with her daughter and son in law, and that they had been providing for the patient's night time needs. However, they moved away and the patient now lives alone. The patient has extensive night time needs including toileting and bed positioning that the family had been assisting the patient with, but they are no longer able to do so.
Personal care logs from the night care provided by the patient's family were provided for review. The logs showed that the patient's pull up required changing approximately every 3 hours, and she also urinated on the bedside commode at each changing. Attempting to use the commode overnight takes 15-45 minutes each time. Despite using the commode every 3 hours or so, she would still require a pull-up change at the next wakening.
A letter of medical necessity for this appeal was provided by the patient's primary care physician. The letter states that due to her medical conditions, she requires 24-hour care. The physician's office visit notes were also provided for review, which corroborate the patient's medical conditions and functional limitations described elsewhere.
A Uniform Assessment System (UAS) was completed and was available for review. At the time of the assessment, the patient was living with her daughter and her family. She was found to have minimally impaired ability to make decisions. She was alert and oriented to person only. She is able to make her needs known but unable to direct her care. She was never left alone, as either her daughter or son in law were always available for safety monitoring. From a functional standpoint, she requires total dependence for meal preparation, housework, finances, stairs, and transportation. She requires maximal assistance for managing medications, phone use, and shopping. For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, and toilet use. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, bed mobility, and eating. She requires feeding assistance due to tremors. She requires hands on assistance for all ADLs and Instrumental activities of daily living (IADLs). She is frequently incontinent of urine and wears pull ups for episodes of incontinence. She is continent of stool. A task tool associated with the assessment recommended 43 hours per week to address her functional needs. Compared with a prior assessment, the patient did not show significant decline in cognitive or functional status. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services per 15 minutes increase to 24 hours per day (split shift). 

The requested health service/treatment of home care/personal care HHC- level 2 personal care services per 15 minutes increase to 24 hours per day (split shift) is medically necessary for this patient.
The patient's family provided clear evidence that she has personal care needs throughout the day and night. Her family has been providing for her night time needs, and if they are no longer able to do so, it is medically necessary for her to have split shift care. Night logs demonstrate the need for pull up changes every 3 hours overnight. These must be completed in a timely manner; failure to do so could result in skin breakdown and/or infection. A live-in aide would not be able to get a minimum of 5 hours of uninterrupted sleep per night; therefore, split-shift assistance is medically necessary.