Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dependence on Wheelchair.
Treatment: Personal Care Services, 24 hours (hrs.) a day (split shift) 7 days a week for 168 hrs.
The insurer denied Personal Care Services, 24 hours (hrs.) a day (split shift) 7 days a week for 168 hrs.
The determination is upheld.

This is a female patient with a medical history notable for wheelchair dependence. The patient is approved for 24-hour per day live-in personal care, 3 days per week, for a total of 39 hours per week. The patient and her care team requested an increase to 24-hour per day split shift care, 7 days per week, for a total of 168 hours per week. Of note, the patient currently receives live-in personal care 3 days per week from one service and 4 days per week from another service. Due to one of the services being unable to find a suitable aide, the patient and her family are requesting 7-day-per-week personal care from the other service. They are also requesting an increase to split shift-level care.
A Uniform Assessment System (UAS) was completed. The assessment was conducted in person. The patient was alert and oriented to person and place only with periods of confusion and forgetfulness. She can make needs known. Due to muscular dystrophy, the patient is non-ambulatory and wheelchair-bound. She is dependent on others for all activities of daily living. She is frequently incontinent of urine and infrequently incontinent of stool. There was no fall in the previous 90 days. There was no pressure ulcer present.
Office visit notes were available for review. The patient had been recently hospitalized. There is mention of a wound on the buttocks in the history of the present illness. The physical exam states that there is a 5-millimeter (mm) round wound on the right inner buttock with no rash and no skin lesion. There is no discussion regarding recommendations for treatment in the plan. There were no letters of medical necessity provided as part of this appeal. At issue is the medical necessity of Personal Care Services, 24 hours (hrs) a day (split shift) 7 days a week for 168 hrs.

The requested health service of Personal Care Services, 24 hours a day (split shift) 7 days a week for 168 hours has not been demonstrated to be medically necessary for this patient.
The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care would be medically appropriate. Therefore, there is a question of whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.
There is insufficient documentation that the patient has personal care needs which would preclude a live-in care aide from receiving adequate rest at night. There is mention of a small 5 mm wound on the buttock, but there is no request for any particular treatment for this. The patient does have incontinence, but there are no nighttime care logs that describe the frequency of incontinence changes. Therefore, it is not demonstrated that a live-in personal care aide could not receive sufficient rest at night. The requested service has not been demonstrated to be medically necessary.