Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment:  personal care services 24 hours a day split-shift (two 12 hour shifts per day), a total of 168 hours a week
The insurer denied personal care services 24 hours a day split-shift (two 12 hour shifts per day), a total of 168 hours a week
The determination is overturned.

This is a female patient with a past medical history of urinary and bowel incontinence, dementia, diabetes mellitus (DM) type 2, coronary artery disease, and cerebral atherosclerosis who was hospitalized with coronavirus disease (COVID) 19 with subsequent transfer to rehabilitation  who was then discharged to home. The patient underwent a video assessment. The insurer sent an initial adverse determination notice to reduce, suspend, or stop services stating the patient had been approved for personal care assistant (PCA) services 24 hours/day, split-shift, 7 days/week but the plan approval would change to PCA services 24 hours/day, 7 days/week, live-in. The denial stated the community health assessment demonstrated the previous plan authorized more services than were medically necessary and the patient had been assigned PCA services 24 hours/day, 7 days/week, split shift when she was assigned to their plan and these hours were continued under the New York State continuity of care policy.
Following the assessment the plan recommended physical therapy and occupational therapy and to utilize durable medical equipment (DME) in the home. The plan also recommended discussing with her doctor an appropriate support surface to reduce pressure and keep her skin intact which would lessen her need for repositioning as well as utilizing positioning pillows and foam wedges. In addition, the plan recommended heel booties, barrier cream to help keep skin intact, and incontinence supplies. The plan also stated the patient's needs could be met with PCA services 24 hours/day, 7 days/week, live in as the patient's assistance needs were sufficiently infrequent that the live-in aide would likely obtain, on a regular basis, 5 hours of uninterrupted sleep during an 8-hour period of sleep. Lastly, the insurer noted overnight services would not be provided for safety supervision.
The patient's medical provider appealed denial decision with documentation stating the patient required around-the-clock care that could not be provided by a 24-hour live-in home health aide as the patient was bedbound, at risk for skin breakdown, and specifically had nighttime needs such as diaper changes, repositioning, and supervision to prevent her from trying to get out of bed. The provider noted that the frequency of these tasks and the lack of an appropriate place for a caregiver to sleep will preclude the aide from getting at least 5 hours of uninterrupted sleep and the provider was requesting the patient continue to receive PCA services for 12 hours at night and 12 hours during the day.
At issue is the medical necessity of personal care services 24 hours a day split-shift (two 12 hour shifts per day), a total of 168 hours a week.
The services are medically necessary.
There is documentation from the patient's medical provider of the medical necessity of split shift services. The provider specifically notes that the patient requires frequent turning and repositioning every 2 hours as well as frequent diaper changes due to her immobility and dementia. In addition, the provider noted that there is not a space for an aide to sleep and therefore split shift services are necessary. The patient's care needs in the overnight hours are such that a PCA would not be able to obtain 5 hours of uninterrupted sleep. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as the plan suggested. Because of the patient's dementia it would be unlikely that she would benefit from PT or OT services and she is on hospice without a plan for rehabilitation. The requested increase in PCA services to split shift is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours a day split-shift (two 12 hour shifts per day), a total of 168 hours a week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.