Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End-stage renal disease on dialysis
Treatment: Increase in Personal Care Services to 24 hours a day, 7 days a week split shift for a total of 168 hours
The insurer denied increase in Personal Care Services to 24 hours a day, 7 days a week split shift for a total of 168 hours.
The determination is overturned.

This is a female patient with a history of end-stage renal disease on dialysis, hypertension, dementia, peripheral vascular disease, and urinary and fecal incontinence. She lives alone in a private residence, and she is bedbound. The patient was previously approved for Personal Care Services (PCS) 24 hours per day, 7 days per week (live in). The patient and her care team requested PCS 24 hours per day, 7 days per week (split shift). This request was denied by the Plan and this denial was appealed by the patient's granddaughter.
A video Uniform Assessment was completed. A tasking tool was used to determine that she requires 60 hours of aide service per week. The assessor documented the presence of a pressure ulcer with partial loss of skin layers.
The patient's granddaughter states that the patient needs assistance with dressing and toileting (changing her pull-up). She states that her grandmother has a stage 1 pressure sore on her buttock, and she is concerned that she may develop more sores. 
The patient's nephrologist provided a letter of support. He states that she needs total home care and cannot perform and of her own activities of daily living (ADLs). He states she has chronic diarrhea secondary to medications she receives for her kidney disease and needs her pull ups to be changed every 1-2 hours. At issue is the medical necessity of increase in Personal Care Services to 24 hours a day, 7 days a week split shift for a total of 168 hours.

Taking into account plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Services 24 hours per day, 7 days per week (split-shift) is medically necessary.
Per New York Codes, Rules, and Regulations section 505.14, a live-in personal care aide must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. An aide to this patient is unable to receive five hours of uninterrupted sleep for two reasons. First, the patient's nephrologist documented the need for the patient to have her diaper changed every 1-2 hours. As noted in "Pressure Injuries: Prevention, Evaluation, and Management", prevention measures in patients at increased risk of pressure injuries include keeping skin clean (particularly following incontinence events) as increased moisture from urine, stool, and sweat can cause skin maceration and escalate the risk of pressure injuries. Frequent diaper changes every 1-2 hours are necessary to prevent worsening of her current pressure injury and development of new pressure injuries. Secondly, the patient's granddaughter documented that her live-in aide was unable to receive 5 hours of uninterrupted sleep for 20 of the 65 nights documented. Therefore, split-shift care is required to meet the patient's frequent care needs.
The patient's nephrologist documented the need for an increased level of care. The patient lives alone and does not have informal support for the times that a live-in aide must be allowed to sleep. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCS hours is not solely for safety and supervision but to assist the patient with ADLs.