Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic pain, depression, narcolepsy, opioid dependence, anxiety, hypothyroidism, radiculopathy, lumbar compression fracture, weakness, and insomnia
Treatment: Increase Personal Care Services (PCS) 12 hours a day 7 Days per Week (Split Shift) for a Total of 168 Hours
The insurer denied: Increase Personal Care Services (PCS) 12 hours a day 7 Days per Week (Split Shift) for a Total of 168 Hours
The denial is overturned.

This is an adult female. She has multiple conditions, including chronic pain, depression, narcolepsy, opioid dependence, anxiety, hypothyroidism, radiculopathy, lumbar compression fracture, weakness, and insomnia. She lives alone. Denial of increase personal care services (PCS) 12 hours a day 7 days per week (split shift) for a total of 168 hours is being appealed. The health plan approved 84 hours per week.
The patient's Uniform Assessment System Evaluation performed  several months ago shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances, shopping, bathing, lower body dressing, walking, locomotion, and toileting; extensive assistance with managing medications, personal hygiene, upper body dressing, bed mobility, and eating; and limited assistance with phone use. She has bowel and 
bladder incontinence. An appeal statement notes the patient is wheelchair bound. She has a persistent spinal infection after 
26 spinal surgeries. She has a history of falls. Due to the progressive nature of her disease, her ability to complete ADLs (activities of daily living) has declined, and her nighttime needs are more frequent. She awakens every two hours and needs assistance with toileting every three to four hours. A letter from the patient's provider notes the patient needs assistance with toileting, ambulation, transfers, and turning/positioning, dressing, bed mobility, and personal hygiene. There may be unscheduled needs throughout the day. She has frequent falls due to limited mobility.

The requested Increase Personal Care Services (PCS) 12 hours a day 7 Days per 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 increase personal care services (PCS) 12 hours a day 7 days per week (split shift) for a total of 168 hours is being appealed. The health plan approved 84 hours per week. The plan denied an increase in hours, citing that the current hours are sufficient to accomplish the tasks being performed, and that hours can be split into two shifts. This patient has multiple chronic conditions. Uniform Assessment System evaluation completed three months ago shows the patient requires assistance with all ADLs activities of daily living). She is incontinent of bowel and bladder. Appeal statements indicate a progressive decline in the patient's functional status and need for assistance with all ADLs (activities of daily living). Also noted is that the patient needs assistance with toileting ever three to four hours and with bed positioning. The information provided shows that this patient has significant limitations in functioning. The information supports that the patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested increase PCS (personal care service) from 84 hours per week to 12 hours a day 7 days per week (split shift) for a total of 168 hours is medically necessary.