Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Age-related decline, pressure injury of the sacrococcygeal region, chronic obstructive pulmonary disease with oxygen dependence. 
Treatment: Personal Care Services 24 hours a day (split shift), 7 days a week, a
total of 168 hours a week. 

The insurer denied the request for Personal Care Services 24 hours a day (split
shift), 7 days a week, a total of 168 hours a week. The insurer approved Personal
Care Services, 24 hours a day, live-in, 7 days a week, a total of 91 hours a week. 

The denial is overturned. 

The patient is a senior female with multiple medical conditions, including an unstageable pressure injury of the sacrococcygeal region, age-relate decline, and COPD (chronic obstructive pulmonary disease) with oxygen dependence.  She lives with her husband in a two-bedroom apartment. 

The UAS (Uniform Assessment System) evaluation shows that the patient needs assistance with meal preparation, housework, laundry, shopping, dressing, bathing, toileting personal hygiene, and bed mobility.  She has bladder incontinence. 

An appeal letter from a provider notes the patient was hospitalized for ten days for sepsis due to wound infection. The letter notes the patient needs assistance with bed mobility and repositioning.  The letter requests split shift to attend the patient's needs for repositioning. 

Another appeal letter from a provider notes that the patient's chronic conditions impair her mobility.  She is mostly wheelchair bound.  The letter notes that the patient developed bed sores due to being left in wet diapers without being turned.  The letter recommends the patient be turned/repositioned continuously during day and night. 

This is an appeal for denial of request for an increase in Personal Care Services to 24 hours a day, split shift, 7 days a week, a total of 168 hours a week. The patient has been approved for Personal Care Services, 24 hours a day, live-in, 7 days a week, a total of 91 hours a week. 

Yes, the Personal Care Services 24 hours a day (split-shift), 7 days a week, a total of 168 hours a week 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 provider five hours daily of uninterrupted sleep during the aide's shift. 

This patient has multiple chronic conditions including an unstageable sacrococcygeal pressure injury.  The UAS (Uniform Assessment System) evaluation shows the patient needs assistance with meal preparation, housework, laundry, shopping, dressing, bathing, toileting personal hygiene, and bed mobility.  Appeal statements note the patient was hospitalized with sepsis due to wound infection.  The patient has incontinence, limited bed mobility, and requires frequent turning/repositioning during day and night.  This patient has continuous needs for wound care and repositioning that cannot be met with the approved Personal Care Services, 24 hours a day, live-in, 7 days a week, a total of 91 hours a week.  As such, the requested 24 hours a day, split shift 7 days a week, a total of 168 hours a week is medically necessary for this patient.