Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Incontinence. 
Treatment: Increase in personal care services from 24 hours per day (Live-In) to 24 hours per day (Split-Shift). 
The insurer denied: Increase in personal care services from 24 hours per day (Live-In) to 24 hours per day (Split-Shift). 
The denial is overturned. 

The patient is a female with medical history notable for arthritis with mobility difficulty, urinary incontinence, coronary artery disease, history of myocardial infarction, and diabetes. She had a recent complex hospitalization and subsequent stay at skilled nursing facility due to decline in functional status. The patient was approved for 84 hours per week of personal care services prior to the hospitalization. The patient and her care team requested an increase in services to 24 hours per day split-shift. The health plan partially denied this request but did approve 24 hours per day live-in assistance. 

The denial of split-shift services is the subject of this review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to be alert and oriented with cognition intact. On functional evaluation, she was found to require total dependence for meal preparation and housework. She requires maximal assistance for managing medications and finances. She is independent with phone use. For her activities of daily living (ADL's), she requires total dependence for dressing upper body, dressing lower body, locomotion, and toilet use. She is independent for eating and hygiene. She requires extensive assistance for bed mobility. She is incontinent of both urine and stool with "no control present." She uses about 4 briefs daily. She was being treated for urinary tract infection at the time of the evaluation. For current treatments and procedures, it is noted that she "has pressure ulcers that need to be dressed daily and is bed bound so she has to be turned every 2 hours." 

The health plan's determination is overturned. 

The requested increase in personal care services from 24 hours per day (Live-In) to 24 hours per day (Split-Shift) is medically necessary for this patient.

The patient is already approved for 24 hour live in care, and the question at hand is whether or not it is medically necessary for split-shift care. 24 hour live in aides require the expectation that the aide can regularly get a minimum of 5 uninterrupted hours of sleep per night. If the patient has demonstrated personal care needs that would preclude them from going five or more hours without help from the aide, they would qualify for split shift care. Typically, this is seen in cases of turning and positioning for ulceration treatment and prevention, or for urinary incontinence. In this case, the patient has need for both. She requires assistance for turning every 2 hours as demonstrated by the UAS and recommended by her treating physician. She also has incontinence of stool and urine. Prompt attention to care of soiled briefs is medically necessary to prevent skin breakdown and/or infection, both of which she is already afflicted with. Therefore, it is medically necessary for this patient to receive split-shift care.