Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure
Treatment: Personal Care Services (PCS) 24 hrs. a day split-shift (two 12 hrs. per day), 7 days a week, a total of 168 hrs. a week 
The insurer denied: Personal Care Services (PCS) 24 hrs. a day split-shift (two 12 hrs. per day), 7 days a week, a total of 168 hrs. a week 
The denial is overturned.

The patient is a female with medical history notable for congestive heart failure, bladder and bowel incontinence, morbid obesity, bedbound due to mobility issues, left monoplegia (arm), and cognitive impairment.
Support for this appeal was provided in the form of a letter from the patient's primary care physician. The treating doctor notes that her cognitive impairment, congestive heart failure, and physical limitations are all contributors to her need for around-the-clock care. In particular, toileting has been a major issue with unscheduled needs around the clock. She notes that her "current aide reports that she frequently finds [the patient] soiled with stool and urine when she comes in to care for her...[the patient] is unaware of her bowel and bladder incontinence, she must be checked regularly, and soiled diapers must be changed promptly -- even overnight." The physician notes that failure to do so would place her at risk for skin breakdown. Additionally, she is noted to have physical limitations that prevent her from performing her own turning and positioning in bed.
The most recent office visit note was provided which outlined a workup for some shortness of breath and was otherwise unremarkable.
A Uniform Assessment System (UAS) comprehensive community health assessment was performed. She was noted to require maximal assistance for meal preparation and shopping. She requires total dependence for housework. She requires extensive assistance for finances, managing medications and shopping. With regards to activities of daily living, she requires maximal assistance for bathing and bed mobility. Total dependence is required for dressing lower body, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene and dressing upper body. She is bed bound with left arm contracture which seriously limits her ability to perform activities of daily living (ADL) and Instrumental activities of daily living (IADLs). She is frequently incontinent of both stool and urine.
The subject under review is the medical necessity for the increase in personal care services (PCS) to 24 hours a day split shift (two 12 hrs. per day), 7 days a week, a total of 168 a week.

The requested health service/treatment of Personal Care Services (PCS) 24 hours a day split-shift (two 12 hours per day), 7 days a week, a total of 168 hours a week is medically necessary for this patient. The plan's approval for 24-hours per day of live in care assumes that the patient's need can be met with a minimal amount of help overnight, such that the live-in aide would be able to get at least 5 hours of uninterrupted sleep per night. However, the treating primary care physician notes that the patient has issues overnight and is often found in the morning with soiled diapers because she cannot make her needs known, likely due to her cognitive impairment and other factors. Additionally, the patient cannot change her bed position on her own and frequent turning/positioning was recommended by her treating physician. Due to her around-the-clock unscheduled needs, it is not reasonable to expect that she could go 5 hours every night without intervention. Failure to provide adequate toileting support and diaper care would likely lead to skin breakdown, yeast infections, and other complications.