Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer- Acute Myeloblastic Leukemia.
Treatment: Home Health Care/consumer directed personal assistance services (CDPAS) hours to 24 Hours a day, 7 days a week (split-shift).
The health plan denied the requested increase in consumer directed personal assistance services (CDPAS) hours to 24 Hours a day, 7 days a week (split-shift) as not medically necessary.  
The health plan's determination of medical necessity is overturned in whole. 

This is a case review for a female with a medical history notable for acute myeloblastic leukemia and dementia. The patient is approved for 40 hours per week of consumer directed personal assistance services (CDPAS). The patient and her care team requested an increase to 24-hour care (2-12-hour split-shifts) and this request was denied by the health plan.
The patient's physician from hospice home care provided a letter of support for this appeal. The letter states that the patient's leukemia is a terminal diagnosis and she is on hospice care. She has several comorbid illnesses as well including chronic obstructive pulmonary disease (COPD) on home oxygen and osteoporosis. She has had a significant functional decline over the past several months. She is now bedbound/chairbound and requires a multiple-person assist for all transfers. She has an unstageable sacral pressure ulcer and the physician recommends turning and repositioning in bed every 2 hours to promote healing. She has incontinence and the physician recommends prompt diaper changes to prevent skin breakdown. The patient's family is involved in helping with her more skilled medical needs but are not able to meet all of the personal care needs of the patient.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone in her apartment and receives CDPAS from her granddaughter. The patient was alert and oriented to person and place only. She is able to direct her own care and call for help in an emergency. For her instrumental activities of daily living (IADL), she requires total dependence for meal preparation, housework, and stairs. She requires maximal assistance for transportation and shopping. She requires extensive assistance for finances and medications. For her activities of daily living (ADL), she requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires total dependence for locomotion. She requires extensive assistance for dressing upper body. She requires limited assistance for hygiene, bed mobility, and eating. She is wheelchair bound and requires assistance with transfers. She requires oxygen around the clock. She is frequently incontinent of urine and infrequently incontinent of stool. She uses pullups for incontinence care.
At issue is the medical necessity for the requested health service/treatment of increase in CDPAS hours to 24 Hours a day, 7 days a week (split-shift).

The health plan's determination of medical necessity is overturned, in whole.

The requested health service of increase in CDPAS hours to 24 Hours a day, 7 days a week (split-shift) is medically necessary for this patient.
The patient has a terminal illness and is on hospice. Her condition is expected to continue to decline. The physician caring for the patient provided a letter which gives the most up-to-date patient status. She is unable to do any ADL without human assistance including toileting and transfers. She is incontinent of urine and requires assistance with changing pullups. She has a pressure ulcer that requires turning and repositioning every 2 hours throughout the day and night to promote healing. Her personal care needs are expected to be continuous and unscheduled throughout the day and night. Therefore, split-shift personal care services are medically necessary and reasonable for the patient.