Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overactive bladder, arthritis, heart failure, and
insomnia
Treatment: Personal Care Service, 7 days week, 24 hours a day (split shift)
The insurer denied the Personal Care Service, 7 days week, 24 hours a day (split shift)
The denial is overturned.

This female patient has medical conditions including overactive bladder, arthritis, heart failure, and insomnia.  She is appealing denial of personal care service (PCS), seven days per week, 24 hours per day, split shift.  The health plan is reducing hours to live-in.  
 
Uniform Assessment System (UAS) evaluation completed showed minimally impaired cognition and functional status: total dependence with housework, and locomotion; maximal assistance with meal preparation, phone use, bathing, personal hygiene, dressing, and toilet use; extensive assistance with managing medications, walking, toilet transfer, bed mobility, and eating. 

A letter states the patient needs split shift care due to inability to self-transfer out of bed and persistent urinary needs.  She uses the bathroom at least every one to two hours.  She is unable to reposition herself in the bed and requires frequent repositioning due to arthritis.  It notes the patient is continent of bowel and bladder. 

A letter from her daughter notes that the patient is unable to position herself in the bed.  She has urinary frequency and requires assistance with bedside commode.  Letters from the patient's provider state the patient needs around the clock care and assistance with everyday needs.  Logs have been provided showing frequent bathroom activity.

Yes, the proposed treatment, personal care service, seven days per week, 24 hours per day (split shift), is medically necessary.

No, the health plan did not 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.

This patient has several chronic conditions.  She is appealing denial of personal care service (PCS), seven days per week, 24 hours per day, split shift.  The health plan is reducing hours to live-in.  Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs).  The appeal information provided shows the patient has cognitive and physical limitations that require assistance throughout the day and night.  She has urinary frequency and needs assistance with toileting every one to two hours due to inability to self-transfer.  This has been supported by logs.  The patient is unable to reposition herself in bed and requires frequent turning/repositioning.  This patient has significant physical impairments and requires assistance that would not allow an aide five hours daily of uninterrupted sleep during the aide's shift. The proposed personal care services, seven days per week, 24 hours per day, split shift is medically necessary.