Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal - CVA with left sided paralysis.
Treatment: Home Health Care.
The insurer denied Personal Care Aide Service- 7 days per week, 2-12 hours ( split shift).
The denial is overturned. 

This patient is a female with a past medical history of cerebrovascular accident (CVA) with resultant left sided paralysis, Alzheimer's dementia, hypertension, dysphagia, and incontinence of urine and bowels. The patient was receiving 7 days per week, 2-12-hour split shift personal care assistance. The plan decided to reduce the services to 7 days per week live-in assistance. The patient's advocate appealed this decision, and the appeal was denied. Support for this appeal is provided by a letter on the patient's behalf noting that the patient requires split shift 24/7 services due to her needs for turning and positioning to prevent ulcers.
The supporting documentation includes a letter from the patient's daughter on her behalf. The daughter lives with the patient, but she works night shift and is not available overnight to help with her care.
A Uniform Assessment System - New York Comprehensive Community Health Assessment was completed. The patient has cognitive impairment and is nonverbal. She is alert to her daughter's voice only. She makes no intelligible communication. With regards to her functional status, she requires total dependence for nearly all activities of daily living and instrumental activities of daily living, including bathing, hygiene, dressing, toileting, and bed mobility. She is not able to walk or transfer to the toilet. She is unable to change her position, and thus requires turning and positioning every 2 hours. She uses diapers for incontinence of bowel and bladder. She is not able to express her needs due to severe cognitive impairment and nonverbal status. She needs to be fed pureed thick liquids. Her skin is intact without evidence of a pressure ulcer.
At issue is the medical necessity of Personal Care Aide Service- 7 days per week, 2-12 hours ( split shift).

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

The requested health service/treatment of Personal Care Aide Service- 7 days per week, 2-12 hours ( split shift) is medically necessary for this patient.
The health plan's denial states that the patient's needs can be met with live-in personal care, which implies that the patient can go 5 hours without care overnight. This is not a reasonable expectation in a patient who is bedbound and requires repositioning every 2 hours. Furthermore, she has incontinence of both bowel and bladder with numerous unscheduled needs. She is unable to voice her needs due to her nonverbal status. If she were left without supervision for 5 hours, she would be left in soiled garments for hours. This would result in skin breakdown, decubitus ulceration, and/or recurrent urinary infections and fungal infections. These needs are present regardless of whether the patient has a pressure ulcer reducing bed, which the patient's daughter states is not true. Even if she did have one, it would not negate her needs for 2-12 hours (split-shift) care.
Therefore, the requested health service/treatment of Personal Care Aide Service- 7 days per week, 2-12 hours ( split shift) is medically necessary.