Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease with stents, congestive heart failure, stroke, hypotension, valvular heart disease, cardiac arrhythmia, permanent pacemaker, carotid occlusion of the right internal carotid artery, left hemiparesis, disequilibrium, multiple falls/fractures, incontinence of the bladder and bowel and diabetes mellitus.
Treatment: Personal Care Worker (PCW) service of 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person.
The insurer denied coverage for PCW service of 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person.
The denial is overturned.

This male has extensive medical history associated with significant functional impairment and needs substantial assistance for all daily activities. He lives with his spouse who is unable to assist the patient due to spouse's health issues. A recent Uniform Assessment System (UAS) comment guide indicates this is not a mutual case. The UAS indicates a sibling provides some informal help with daily tasks, but the patient primarily relies on PCW services for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient had been receiving PCW 39 hours per week. The patient requested increase of PCW services to 7 days per week, 24 hours per day: 168 hours per week, continuous care. The request was denied, but the insurer approved PCW 9 hours per day, 7 days per week, total of 63 hours per week. Appeal was requested, but the insurer upheld denial of 24 hours continuous split shift services. An external appeal was requested.

It is apparent the patient had significant functional decline for ADLs and IADLs. Functional decline in older people is usually the result of cumulative and interactive effects of multiple medical conditions resulting in physical and/or cognitive impairment. Other factors include economic and social circumstances, such as caregiver support. The patient has several medical conditions that contribute to his impaired ability to perform daily activities.

The patient's medical history and functional status support medical necessity for 24-hour personal care services. As per state regulations for personal care services, 24-hour care can be provided as live-in services or continuous (split shift) services. In order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8-hour sleep period each day. If the patient's care needs are of such frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services are indicated, such as split shift.  

The PCW assists with all routine IADLs and ADLs during the day, plus ADLs that occur at unscheduled and recurring times through the day and night. The frequency of the patient's care needs does not appear compatible with the sleep requirements for PCW live-in services. It appears unlikely that a live-in aide could provide all necessary IADL and ADL care and have 5 uninterrupted hours of sleep per day on a regular basis. Therefore, PCW continuous services (split shift) are indicated.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for PCW service of 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person is reversed. Medical Necessity is substantiated.