Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident 
Treatment: Home Health Care (HHC) - Level 2 Personal Care Services (PCS), per 15 Minutes: 24 Hours/Day (2 x [times] 12 Hour Split Shifts of Care)
The insurer denied HHC - level 2 PCS, per 15 minutes: 24 hours/day (2 x 12 hour split shifts of care).
The determination is overturned.

This is a male patient with a medical history notable for a prior cerebrovascular accident (CVA) with resulting hemiparesis, bed bound status, advanced dementia, and incontinence of urine and stool. The patient is currently approved for 24 hours/day, 7 days/week (live-in) of personal care services (PCS). The patient and his care team requested an increase to 24 hours/day (2-12 hour split-shift), 7 days/week (168 hours/week), and this request was denied by the health plan.

A letter of medical necessity for this appeal was provided by the treating physician. The letter states that he has declined since a hospitalization with a CVA and coronavirus disease (COVID). He has severe dementia with confusion and insomnia. He is completely incontinent of stool and urine. He is unable to turn himself in bed. He is fully dependent on a caregiver help for all activities of daily living (ADLs). The physician states he needs overnight assistance with turning and positioning along with diaper changes to prevent pressure ulcer formation.

A letter of support for this appeal was provided by a patient advocate. The letter states that the patient is bed bound and cannot reposition himself in bed overnight or change soiled diapers. Due to his dementia "he yells at night and he is always screaming for help."

A Uniform Assessment System (UAS) was completed and was available for review. Cognition was severely impaired. The patient was confused and disoriented, and unable to direct his own care. For his instrumental activities of daily living (IADLs), he requires total dependence for meals, housework, finances, and shopping. For his ADLs, he requires total dependence for bathing, dressing lower body, locomotion, and toilet use. He requires maximal assistance for hygiene, dressing upper body, and toilet transfer. He requires extensive assistance for bed mobility and eating. He is frequently incontinent of urine and occasionally incontinent of stool. Compared with a prior UAS, he showed a decline in both cognition and functional status. At issue is the medical necessity of Home Health Care (HHC) - level 2 PCS, per 15 minutes: 24 hours/day (2 x [times] 12 hour split shifts of care).

The requested health service of HHC - level 2 PCS, per 15 minutes: 24 hours/day (2 x [times] 12 hour split shifts of care) is medically necessary for this patient.

The patient is receiving 24 hour live-in care and is requesting split-shift. Live-in aides require the expectation of at least 5 hours per night of uninterrupted rest. If this is not possible due to the patient having personal care needs that would preclude this 5 hour window of rest, then the health plan must approve split-shift care. The patient's physician, his advocate, and the UAS all corroborate that he has functional needs that would preclude being left alone overnight. He has incontinence of stool and urine which he cannot manage himself or even make his needs known. Prompt changing of diapers is necessary to prevent infection and/or skin breakdown. He also requires caregiver support for frequent turning and repositioning, as recommended by his physician. These are personal care needs and not merely for safety monitoring of the patient.