Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hemiplegia, traumatic brain injury
Treatment: Personal Care Aide Services from SNF to 7 days per week, 24 hours a day Split - shift
The health plan denied Personal Care Aide Services from SNF to 7 days per week, 24 hours a day Split - shift.
The determination is overturned in part. 

This is a female patient with a medical history notable for hemiplegia, traumatic brain injury, aphasia, incontinence, and status post right leg amputation. The patient is approved for 56 hours per week of personal care aide services. The patient and her care team requested an increase to 24-hour split-shift care, 168 hours per week.

The patient states that she has been in a rehabilitation and nursing facility for over a year but that she would greatly like to return home. She was previously living at home with her husband and they provided informal support to each other, but her husband is no longer living at home. She was also receiving 12 hours per day of personal care time. Between her own worsening functional status and loss of support from her husband, she feels that she needs 24-hour care. She reports general community support from friends and family in the community, but no consistent informal support. She is requesting overnight care because she needs to use the bathroom two to three times per night. She also has incontinence and needs assistance with cleanup and changing after these episodes. She requires assistance with all transfers. 
Nursing home case management review notes and physical therapy notes were provided and reviewed in detail. There were no letters of medical necessity from her treating physicians.
A Uniform Assessment System (UAS) was completed and was available for review. The patient relies on a motorized scooter for mobility due to prior right leg above the knee amputation, hemiplegia of the right side, and ataxia. The patient was alert and oriented times three but forgetful. Her short-term memory was intact. She is able to describe an emergency plan. At issue is the medical necessity of Personal Care Aide Services from Skilled Nursing Facility (SNF) to 7 days per week, 24 hours a day Split - shift.

The requested health service of Personal Care Aide Services from SNF to 7 days per week, 24 hours a day split - shift has not been demonstrated to be medically necessary for this patient. Personal Care Aide Services 24-hour live-in are medically necessary for the patient.
The patient has severe functional limitations due to her medical conditions as described above. The documentation clearly notes that she requires assistance with essentially all activities of daily living, including needing hands-on assistance for toileting and for managing incontinence care products. Therefore, her personal care needs can be expected to be continuous and unscheduled throughout the day and will occur at night as well. The patient will require 24-hour care. However, there is insufficient evidence that the patient meets the requirement for 24-Hour split shift care. The patient does not require turning and repositioning in bed for pressure ulcer. Her nighttime care need frequency has not been clearly delineated. She can receive assistance to the bathroom at night as requested with the help of a live-in aide. A live-in aide requires a minimum of 5 hours of uninterrupted sleep per night, and the true frequency of her nighttime care needs was not described in the documentation in this review. Therefore, a live-in personal care aide has been shown to be medically necessary and appropriate for the patient.