Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall risk. 
Treatment: Personal care services 7 days x 24 hours 2 x 12 (split shift) per week. 

The insurer denied personal care services 7 days x 24 hours 2 x 12 (split shift) per week. 
The determination is overturned. 

This is a male patient with a medical history notable for dementia, urinary incontinence, gait difficulties, atrial fibrillation, hypertension, and type 2 diabetes. The patient is approved for 12 hours per day, 7 days per week (84 hours per week) of personal care services. The patient and his care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week) and this request was denied by the health plan. 

The patient was admitted to the hospital with altered mental status and a fall. He was treated for a mild acute kidney injury with an elevation of creatinine kinase but did not suffer any traumatic injuries. He was discharged in stable condition to a skilled nursing rehabilitation facility. He is currently awaiting the outcome of this appeal as part of a safe discharge plan back to the community. 

A letter of support for this appeal was provided by the patient's physician. The letter states that the patient suffered a fall 2 months ago and was hospitalized. He was discharged to a post-acute rehab program and is now homebound and bedbound, and relies on a wheelchair for locomotion. The physician states that he requires maximal assistance to total dependence for all activities of daily living. The physician recommends turning and positioning in bed every 2 hours throughout the day and night. He also requires assistance with toileting and changing incontinence supplies. He has these requirements "at unscheduled times throughout the day and also at night so frequently that an aide cannot sleep 5 hours consecutively, and cannot sleep a total of 8 hours at night." The patient lives alone and has no informal support to help with his personal care needs. 

A letter of support for this appeal was provided by the patient's attorney, along with the patient's medical records. These were reviewed in detail as part of this review.
A Uniform Assessment System (UAS) was completed and was available for review. The evaluation was done via teleconference while the patient was in the skilled nursing facility. The patient's cognition was moderately impaired. He was alert and oriented to person only and recalled 0/3 words at five minutes. He is unable to direct his own care. From a functional standpoint, he requires total dependence for meal preparation, housework, finances, stairs, and shopping. For his activities of daily living (ADLs), he requires total dependence for bathing, dressing lower body, locomotion, toilet transfer, and toilet use. He requires maximal assistance for hygiene, dressing upper body, and bed mobility. He is incontinent of urine and stool with no control present. He wears diapers for incontinence care. Compared to a prior Uniform Assessment System (UAS) prior to the fall, he showed a decline across functional domains. At issue is the medical necessity of personal care services 7 days times (x) 24 hours 2 x 12 (split shift) per week. 

The requested health service of personal care services 7 days x 24 hours 2 x 12 (split shift) per week is medically necessary for this patient. 
The patient has dementia and cannot direct his own care. He requires maximal assistance to total dependence for all activities of daily living. He requires turning and repositioning in bed every 2 hours throughout the day and night as requested by his physician. The UAS also indicates that he is not capable of turning and repositioning independently. He is completely incontinent of urine and stool and will have unscheduled toileting and changing needs throughout the day and night. For patients that require continuous personal care for scheduled and unscheduled needs, split-shift 24-hour personal care is medically necessary and appropriate. Failure to provide for these personal care needs could result in skin breakdown and/or infection.