Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, COVID (coronavirus), hypertension, congestive heart failure.
Treatment: Increase of personal care services to 24 hours per day.

The insurer denied coverage for increase of personal care services to 24 hours per day.
The denial is upheld.

This male patient has significant functional decline related to several medical conditions and needs assistance with all daily activities. The patient receives personal care services (PCS) 8 hours per day, 7 days per week, 56 hours per week. The patient had two recent hospitalizations and his functional status declined. Patient (via designee) requested increase in PCS to 24 hours per day, 7 days per week, split shift, which was denied. An external appeal was requested. 

The uniform assessment system (UAS) functional status report indicates patient is totally dependent or needs maximal assistance for most instrumental activities of daily living (IADLs) except phone use (extensive assistance). For activities of daily living (ADLs), he needs maximal assistance for bathing, dressing lower body, locomotion, toilet use; extensive assistance for personal hygiene, dressing upper body; limited assistance for bed mobility, eating. It was reported the patient does not walk, and he is not transferred to the toilet. Bathing: extensive assist (maximal assist); personal hygiene: supervision (extensive assist); dressing upper body: limited assist (extensive assist); walking: extensive assist (did not walk); locomotion: extensive assist (maximal assist); toilet transfer: extensive assist (did not occur); toilet use: extensive assist (maximal assist); bed mobility and eating setup help only (limited assist).

As per the UAS, toilet transfer did not occur (this appears to apply to commode also, as there is no mention of commode use). The UAS reported patient relies on diapers and it was noted that the patient has up to 10 diaper changes per day. Bladder and bowel incontinence were both noted as frequent. The UAS reported patient needs maximal assistance with toilet use which includes incontinence care. Skin exposure to wet soiled diapers for an extended period increases risk of skin damage (e.g., fungal infection, dermatitis), increases risk of pressure ulcers, and causes patient discomfort. Fecal incontinence can increase risk of urinary tract infection. The patient needs caregiver assistance throughout the day and night to provide prompt cleaning when incontinence occurs. Pressure ulcers are a source of pain and can result in infection/sepsis and possibly surgical intervention. Pressure ulcer prevention is a priority for the patient's care plan. This includes a caregiver to assist with repositioning on a regular basis (this may occur during incontinence care, which requires repositioning in bed for cleaning and diaper change).

Based on the records provided for review, it is medically necessary for the patient to have a caregiver present to aid with all daily activities including routine instrumental activities of daily living (IADLs) and ADLs, and ADLs that occur at unscheduled and recurring times of the day and night. Considering the frequency of care the patient needs during the day and night, it does not appear his care needs can be adequately met within the service hours provided by a live-in aide. Therefore, continuous personal care services (split shift) are indicated. Re-assessment will determine whether the patient's functional status improves, and if the plan needs to be modified. 

Recommendation is given to approve Personal Care Services level 2, 24 hours per day, 7 days per week, (split shift), total 168 hours per week.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an increase to 24 hours per day, 7 days per week (Split-Shift)- a total of 168 hours per week, for Personal Care Services (PCS) is upheld. Medical Necessity is substantiated.