Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence, Gait Dysfunction, Congestive Heart Failure
Treatment: Personal Care Assistance services, 24 hours per day (split shift), 7 days per week, (Monday through Sunday), for a total of 168 hours per week.
The insurer denied the Personal Care Assistance services, 24 hours per day (split shift), 7 days per week, (Monday through Sunday), for a total of 168 hours per week.
The health plan's determination is overturned.

The patient is a female with a medical history notable for incontinence, gait dysfunction, and congestive heart failure. The patient is currently approved for 12 hours per day, 7 days per week (84 hours per week) of personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week), and this request was denied by the insurance company.

The patient's nurse practitioner (NP) provided a letter of medical necessity for this increase. The letter states that the patient has had a rapid physical and cognitive decline. She cannot walk independently and is wheelchair bound. She has urinary and fecal incontinence and requires multiple diaper changes throughout the day and night. The letter also requests assistance with every 2 hours turning and repositioning in the bed at night due to her decline.

A community advocate provided a letter of support for this appeal. The letter states that she is "mostly bed-confined and wheelchair dependent." She reiterated the concerns of the NP, that the patient needs nighttime help with diaper changes and repositioning in bed. The notes state that she is left alone overnight and when her aide arrives in the morning she is in a urine and feces filled diaper and is very uncomfortable.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service of Personal Care Assistance services, 24 hours per day (split shift), 7 days per week, (Monday through Sunday), for a total of 168 hours per week is medically necessary for this patient. The patient has dementia, incontinence, and gait dysfunction.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was oriented to person only with moderately impaired cognition. She is unable to direct her own care or activate 911 in an emergency. The patient's recall is 0 out of 3 at five minutes. For her Instrumental activities of daily living (IADL's), she requires total dependence for housework. She requires maximal assistance for finances, medications, shopping, and transportation. For her activities of daily living (ADL's), she requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfers, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She is frequently incontinent of urine and infrequently incontinent of stool. She uses pullups for incontinence care and requires assistance with changing. A task tool associated with the assessment recommended 50 hours per week to address her personal care needs.

She relies on others for transfers and all IADL's and ADL's including toileting. Her personal care needs can be expected to be continuous throughout the day and night and by definition will be unscheduled. She cannot toilet independently and cannot change a soiled diaper after episodes of incontinence. If she is left alone for 12 hours, she would not have any ability to transfer or toilet and would potentially be left in soiled diapers during that time. This could result in skin breakdown and/or infection.

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