Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic prostate cancer, Parkinson's disease, and osteoarthritis. 
Treatment: Increase Personal Care Service Hours to 24 Hours a Day, 7 Days a Week (Split Shift) for a Total of 168 Hours per Week
The insurer denied: Increase Personal Care Service Hours to 24 Hours a Day, 7 Days a Week (Split Shift) for a Total of 168 Hours per Week
The denial is overturned.

This elderly male patient has medical conditions that include metastatic prostate cancer causing cord compression and lower extremity paralysis, Parkinson's disease, and osteoarthritis. 
The denial of an increase in personal care service hours to 24 hours a day, 7 days a week (split shift), for a total of 168 hours per week is being appealed. The health plan approved 60 hours per week. Uniform Assessment System evaluation completed four months ago shows minimally impaired cognition and need for assistance with all activities of daily living, except supervision with eating. He was bedbound. He has bowel incontinence. 
An appeal statement from New York State reports the patient was recently hospitalized in April with sudden onset of paralysis and incontinence. He is unable to toilet on his own. He has a bed sore. The assessments provided were performed before his hospitalization and rehab stay. His providers have recommended turning/repositioning every 2 hours. A letter from the Provider notes the patient is a patient in rehab. He has limited ability to move his legs. He is bedbound and homebound. He cannot turn or reposition himself in the bed. He has bowel incontinence and needs assistance with changing. A letter from another Provider notes the patient is fully dependent for activities of daily living and requires repositioning every 2 hours. The Home Health Aide logs do not support daily nighttime continuous care.

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions, including recent admission for sudden lower extremity paralysis and incontinence. The denial of an increase in personal care service hours to 24 hours a day, 7 days a week (split shift), for a total of 168 hours per week is being appealed. The health plan approved 60 hours per week. The plan noted that nighttime logs show the patient sleeping 6 hours per night and denied services for safety supervision and companionship, and recommended the approved hours be split. Uniform Assessment System evaluation completed four months ago shows the patient requires assistance with all activities of daily living, except supervision with eating. He is bedbound and incontinent of bowel. The appeal statements support the patient is dependent with all activities of daily living and requires frequent assistance with toileting, transfers, and turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved personal care service 60 hours per week is insufficient to meet the patient's continuous needs. The proposed increase to 24 hours a day, 7 days a week (split shift), for a total of 168 hours per week is medically necessary.