Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic lymphocytic leukemia (CLL), dizziness, insomnia, depression, overdrive bladder, urge incontinence, weakness, abnormal gait and mobility, and left leg wound
Treatment: Increase Consumer and Self Directed Personal Care Assistance Services To 24 Hours A Day, 2 Days A Week (SPLIT SHIFT), 48 hours total, Pre-service
The insurer denied the Increase Consumer and Self Directed Personal Care Assistance Services To 24 Hours A Day, 2 Days A Week (SPLIT SHIFT), 48 hours total, Pre-service
The denial is overturned.

This male has conditions including chronic lymphocytic leukemia (CLL), dizziness, insomnia, depression, overdrive bladder, urge incontinence, weakness, abnormal gait and mobility, and left leg wound.  He is appealing denial of 24 hour split shift personal assistance services (PAS), two days per week.  He is approved for 60 personal assistance service (PAS) hours per week.  

The patient lives with his spouse who also receives homecare services.  Assessment performed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances and medications, phone use, stairs, and shopping; extensive assistance with bathing, and personal hygiene, dressing, locomotion, toileting, walking; and limited assistance with bed mobility and eating.  Frequently incontinent of bladder and occasionally incontinent of bowel.  The patient was admitted with COVID.  Has decline in cognitive and functional status since hospitalization.  Durable medical equipment (DME) includes walker, wheelchair, shower chair, grab bar, commode and personal emergency response system (PERS). A statement from the patient's provider notes the patient is high risk for falls and has overall weakness.  Due to double vision and unsteady gait, he is high risk for falls.  It states the patient is incontinent and needs assistance with changing and toileting.  A letter from a relative notes the patient is unable to walk or get out of bed without assistance. The relative has gone to the house on several occasions in the night after the patient has fallen.  A letter from paramedic notes the patient's memory is failing. He needs night and day help with changing after being incontinent.  The patient was admitted with COVID pneumonia and acute respiratory distress syndrome (ARDS).

Yes, the proposed  treatment, Increase Consumer and Self Directed Personal Care Assistance Services To 24 Hours A Day, 2 Days A Week (SPLIT SHIFT), 48 hours total, is medically necessary.
Medically necessary services are those which are:
safe 
effective
generally accepted national standard of medical practice 
not provided primarily for convenience of the patient or the practitioner 
the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding.  Personal care service is necessary when assistance cannot be met from use of from informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

This patient was approved for 60 hours personal assistance services (PAS) per week.  The patient is appealing denial of 24 hour split shift personal assistance services (PAS), two days per week.  The patient has multiple chronic medical conditions.  His cognitive and physical functioning have declined since hospitalization for COVID pneumonia.  Assessment performed shows the patient requires assistance with all activities of daily living and instrumental activities of daily living (IADLs) with the exception of bed mobility and eating where he requires limited assistance.  He lives with his wife who also requires personal assistance services (PAS).  The appeal letters show the patient has poor functional status with unsteady gait requiring assistance with mobility to prevent falls.  He requires assistance with toileting and diaper changes that occur throughout the entire day.  The approved 60 hours personal assistance services (PAS) per week are inadequate to meet the patient's needs with activities of daily living / instrumental activities of daily living including walking, toileting and transfers that occur throughout the entire day.  The proposed increase personal assistance services to 24 hour split shift, two days per week, is medically necessary to meets this patient's need for assistance with activities of daily living and personal care.