Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision/Other/Wet Macular Degeneration
Treatment: Home Health Care/24 hours per day, 7 days per week (2 Shifts of 12 hours of aide service) Level 2 Personal Care Aide Service 
The health plan denied the requested 24 hours per day, 7 days per week (2 Shifts of 12 hours of aide service) Level 2 Personal Care Aide Service as not medically necessary. The health plan's determination is upheld.

This is a case review of a female with a medical history notable for chronic back pain, tremors, neuropathy, glaucoma, gait dysfunction, and urinary incontinence. The patient is approved for 9 hours per day, 7 days per week (63 hours per week) of level 2 personal care aide services. The patient and her care team have requested an increase to 24 hours per day (2-12-hour split-shift), 7 days per week (168 hours per week).
The patient's home care physician provided a letter of support for this appeal. The letter states that the patient is wheelchair and bed-bound. She requires help with "some of her activities of daily living (ADL)" and is able to direct her care. The patient is receiving daytime care only at this time. The physician requests additional help at night; they state that the patient needs diaper changes as well as help with repositioning in bed every 2 hours to prevent pressure wounds.
A letter of support for this appeal was provided; the letter writer's relation to the patient was not described. The letter states that the assessment contains some factually incorrect information. The letter states that the patient requires a lot of help with hygiene, dressing, and toileting. She has a history of falling in the night while attempting to toilet independently. She will then call on her sister for help (who is 89 years old and legally blind).
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented times three with periods of forgetfulness. She is able to make her needs known. For her instrumental activities of daily living (IADL), she requires maximal assistance for meal preparation, housework, and shopping. She requires limited assistance for finances and medications. For her ADL's, she requires maximal assistance for bathing, dressing lower body, and toilet use. She requires extensive assistance for dressing upper body, walking, locomotion, and toilet transfer. She requires limited assistance with hygiene and eating. She is independent with bed mobility. She is frequently incontinent of urine and uses pullups for incontinence care. Her skin was intact with no evidence of pressure ulcer. A task tool associated with her assessment recommended 33 hours per week to address her personal care needs.
At issue is the medical necessity for the requested health service/treatment of 24 hours per day, 7 days per week (2 Shifts of 12 hours of aide service) Level 2 Personal Care Aide Service.

The health plan's determination of medical necessity is upheld, in whole.

The requested health service of 24 hours per day, 7 days per week (2 Shifts of 12 hours of aide service) Level 2 Personal Care Aide Service has not been clearly demonstrated to be medically necessary for this patient.
The patient has multiple functional limitations. She requires hands-on assistance with toileting, ambulation, and transfers. She has incontinence and requires assistance with diapering. Her care needs can be expected to be continuous and unscheduled. She may require additional help in the home, but there is no evidence that her case qualifies for 24-hour split-shift care. The provision of split-shift services is reserved for individuals that require hands-on personal care assistance throughout the day and night. The physician requested turning and repositioning in bed overnight, but the UAS states that the patient is independent in bed mobility and does not have any pressure ulcers. There are no demonstrated nighttime personal care needs that would necessitate a personal care aide being present to help every 1-4 hours throughout the night.