Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Heart Failure
Treatment: PCS hours  24 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours per Week
The insurer denied PCS hours  24 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours per Week
The health plan's determination is upheld.

This is a female patient with a history of atrial fibrillation, heart failure, osteoarthritis, hypertensive retinopathy, chronic anterior uveitis, chronic angle-closure glaucoma of both eyes, gastroesophageal reflux disease (GERD), hearing loss, vitamin D deficiency, vitamin B12 deficiency, and bladder and bowel incontinence. She lives alone in a private residence. The patient was previously approved for Personal Care Services (PCS) for 12 hours per day, 7 days a week, for a total of 84 hours per week. The patient and her care team requested PCS for 24 hours per day, 7 days per week (split-shift), for a total of 168 hours per week. This request was denied by the plan, and the patient's son appealed this denial.
An in-person Uniform Assessment System (UAS) was completed. The patient was assessed at total dependence for tasks of meal preparation, ordinary housework, stairs, and shopping; maximal assistance for tasks of managing finances, managing medications, phone use, transportation, bathing, personal hygiene, dressing upper body, dressing lower body, walking, locomotion, transfer toilet, and toilet use; and extensive assistance with bed mobility and eating. A tasking tool was used to determine that she requires 55.5 hours of aide service per week.
The patient's primary care physician (PCP) provided a letter of support. Her PCP states that she has severe vision and hearing impairment, which impedes her from accessing emergency services when needed. Per her PCP, she is dependent on caregivers for meal preparation, eating, dressing, and bathing. Her PCP states that she needs someone to supervise her while toileting.
The health plan's determination of medical necessity is upheld in whole.
Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Services (PCS) 24 hours per day, 7 days per week (split-shift), for a total of 168 hours per week, is not medically necessary.
Although the patient requires hands-on assistance with many activities of daily living (ADL) and instrumental activities of daily living (IADL), the documents provided do not support a claim of medical necessity for split-shift care. Per New York Codes, Rules, and Regulations Section (NYCRR) 505.14, split shift care is indicated if a live-in personal care aide would not be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep due to a patient requiring assistance with ADLs. There is no documentation showing that the patient currently requires frequent overnight assistance with specific ADLs or IADLS. There were no night-logs of care required overnight and no physician orders for frequent repositioning. Her PCP notes state that she needs someone to supervise her while toileting, but there is no documentation that requires assistance with this ADL frequently throughout the night. Therefore, there is insufficient evidence of medical necessity for split-shift care. Additional hours are not provided when tasks are not being performed and for safety monitoring and supervision only.