Appeal type: Medical necessity
Decision: Upheld

Diagnosis: age-related cognitive decline, hip fracture, lumbar spine fracture, stroke, prostate cancer, heart disease, diabetes, and repeated falls
Treatment: Increase Personal Care Services To 24 Hours A Day 7 Days A Week (split shift)
The insurer denied the Increase Personal Care Services To 24 Hours A Day 7 Days A Week (split shift)
The denial is upheld

The patient is a male. His conditions include age-related cognitive decline, hip fracture, lumbar spine fracture, stroke, prostate cancer, heart disease, diabetes, and repeated falls. He lives with his wife. Denial of increase personal care services (PCS) to 24 hours a day 7 days a week, split shift, is being appealed. The health plan approved an increase to 59 hours/week.

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, shopping, lower body dressing, and locomotion; maximal assistance with managing finances and medications, phone use, bathing, walking, and toileting; extensive assistance with personal hygiene, upper body dressing, and bed mobility; and limited assistance with eating. The patient uses a wheelchair and scooter for locomotion. He has bowel and bladder incontinence.

A letter from the patient's provider notes the patient has been in inpatient rehab for several months. The letter notes the patient has declines in physical functioning and family barriers that require home care for discharge to home.

A letter from the patient's daughter notes the patient has slow cognitive processing and is being worked up for dementia. The patient needs constant supervision for safety reasons and mobility. His wife will be able to provide some assistance.

No, the requested Increase Personal Care Services To 24 Hours A Day 7 Days A Week (split shift) is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
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 PCS (personal care service) to 24 hours a day 7 days a week, split shift, is being appealed. The health plan approved an increase to 59 hours/week.

The patient has several chronic conditions, including recent hip fracture. He is currently in inpatient rehab. He lives with his wife. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). He has bowel and bladder incontinence. Appeal statements notes there has been a decline in the patient's physical functioning. He has limited informal support. Constant supervision is recommended for safety reasons and mobility. This patient has significant physical limitations. The documentation does not support that the patient needs continuous care or a frequency of care that requires 24 hour-split shift aides, i.e., frequent turning/repositioning. PCS (personal care service) is not indicated for supervision or when no tasks are being performed. The requested increase in PCS (personal care service) to 24 hours a day 7 days a week, split shift is not medically necessary.