Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bladder cancer, kidney disease, low back pain, osteoporosis, hypertension, and multiple rib fractures. 
Treatment: Personal Care Services 24 Hours A Day 7 Days A Week (split shift) for a total of 168 Hours. 
The insurer denied: Personal Care Services 24 Hours A Day 7 Days A Week (split shift) for a total of 168 Hours. 
The denial is overturned. 

The patient is an elderly male. His medical conditions include bladder cancer, kidney disease, low back pain, osteoporosis, hypertension, and multiple rib fractures. He requires CPAP (continuous positive airway pressure) at night. He lives with his elderly wife. Denial of personal care services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours is being appealed. The health plan approved PCS (personal care service) 24 hours a day 7 days a week (live-in). The patient's Uniform Assessment System (UAS) evaluation completed 10 months ago shows moderately impaired cognition and functional status: maximal assistance to total dependence with ADLs (activities of daily living), except extensive assistance with eating. He has frequent bowel and bladder incontinence. Appeal statement reports the patient is bedbound. He requires assistance with all ADLs (activities of daily living) throughout the day and night. His wife is unable to provide support. Logs show the patient getting assistance every 1-2 hours during the day and night. A letter from the patient's provider reports the patient has multiple chronic conditions. The patient is homebound. He needs assistance from an aide throughout the day and night, to include unscheduled care. The frequency of nighttime needs will not allow for 5 hours consecutive sleep. 

The requested Personal Care Services 24 Hours A Day 7 Days A Week (split shift) for a total of 168 Hours 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 aide five hours daily of uninterrupted sleep during the aide's shift. Denial of personal care services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours is being appealed. The health plan approved PCS (personal care service) 24 hours a day 7 days a week (live-in). This patient has multiple chronic conditions. He is bedbound. He lives with his wife, who is unable to provide informal support. Uniform Assessment System (UAS) evaluation completed 10 months ago shows the patient requires maximal assistance to total dependence with ADLs (activities of daily living), except extensive assistance with eating. He is incontinent of bowel and bladder. Appeal statements support the patient's need for assistance with all ADLs (activities of daily living). The statements recommend split shift care due to nighttime needs that will not allow an aide 5 hours of uninterrupted sleep. Logs shows the patient receiving assistance every 1-2 hours with ADLs (activities of daily living). The information provided show that this patient has significant limitations in functioning that cannot be met with currently approved live-in PCS (personal care service). The requested increase in PCS (personal care service) to split shift is medically necessary.