Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vasovagal syncope, neuropathy, arthritis, hearing impairment, edema, macular degeneration, muscle weakness, and unsteady gait.
Treatment: Increase Consumer and Self-Directed Personal Assistance Services; 24 Hours A Day, 7 Days A Week (split shift), a Total of 168 Hours
The insurer denied: Increase Consumer and Self-Directed Personal Assistance Services; 24 Hours A Day, 7 Days A Week (split shift), a Total of 168 Hours
The denial is upheld.

The patient is an elderly female. Her medical conditions include vasovagal syncope, neuropathy, arthritis, hearing impairment, edema, macular degeneration, muscle weakness, and unsteady gait. Denial of increase consumer and self-directed personal assistance services to 24 hours a day, 7 days a week (split shift), for a total of 168 hours is being appealed. The health plan has approved 50 hours per week.
The patient's Uniform Assessment System evaluation completed four months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, shopping, transportation, bathing, lower body dressing walking, locomotion, and toileting; extensive assistance with personal hygiene, upper body dressing, and eating; and limited assistance with managing mediation and finances, and stairs. She has frequent bladder incontinence. No fall are noted in the last 90 days.
A letter from the patient's provider reports the patient was recently hospitalized with sepsis in five months ago. Her muscle weakness and confusion have increased since that time. She is unable to perform ADLs (activities of daily living) without continual assistance.
An appeal statement from the patient's son notes the patient is unable to ambulate, transfer, or toilet without assistance.
Aide logs show the patient receiving frequent assistance with transfer during awake hours. She required assistance with toileting once during the night around 1 AM.

The requested Increase Consumer and Self-Directed Personal Assistance Services; 24 Hours A Day, 7 Days A Week (split shift), a Total of 168 Hours is not 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. Denial of increase consumer and self-directed personal assistance services to 24 hours a day, 7 days a week (split shift), for a total of 168 hours is being appealed. The health plan has approved 50 hours per week.
This patient has multiple several chronic conditions. Uniform Assessment System evaluation completed four months ago shows the patient requires assistance with all ADLs (activities of daily living). She has bladder incontinence. The evaluation does not support the patient has continence needs. The appeal statement from her provider notes that she requires continual assistance with ADLs (activities of daily living) since recent hospitalization with sepsis. Aide logs and UAS (uniform assessment system) evaluation do not support that the patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested 
personal assistance services to 24 hours a day, 7 days a week (split shift), for a total of 168 hours is not medically necessary.