Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Terminal Illness.
Treatment: Increase Home Care/Personal Care Aide To 24 Hours Per Day split-shift.

The insurer denied: Increase Home Care/Personal Care Aide To 24 Hours Per Day split-shift.  The denial is overturned.

The patient is an elderly male. He is terminally ill. He was admitted to hospice home care. Denial of increase in home care/personal care aide to 24 hours per day, split shift, is being appealed. The plan approved 7 days per week, live-in. The health plan denied coverage of the increase, because the patient's medical diagnoses are minimally changed, and he has no nightly needs that cannot be managed with live-in services.
Uniform Assessment System (UAS) evaluation performed recently compared to one completed 4 months earlier shows the patient requires more assistance with medication management and phone use, and less assistance with bathing, personal hygiene, upper body dressing, bed mobility, and meal preparation. A letter from the patient's provider notes the patient has bladder and liver cancer. He requires assistance with transfers and ambulation with walker. Disease progression has resulted in generalized weakness and fatigue. The patient has frequent urination throughout the day and night that often awake him. He requires assistance with turning and repositioning and ambulating to the bathroom. He does have some informal assistance.

The requested Increase Home Care/Personal Care Aide To 24 Hours Per Day split-shift is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split-shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase home care/personal care aide to 24 hours per day, split shift, is being appealed. The plan approved 7 days per week, live-in. The health plan denied coverage of the increase, because the patient's medical diagnoses are minimally changed, and he has no nightly needs that cannot be managed with live-in services.

This patient is terminally ill due to bladder cancer. He is in hospice care. UAS (uniform assessment system) evaluations show the patient needs assistance with medication management phone use, bathing, personal hygiene, upper body dressing, bed mobility, and meal preparation. An appeal statement from his provider notes that the patient's disease has progressed, resulting in generalized weakness and fatigue. He requires assistance with turning, repositioning and ambulating to the bathroom, and he has frequent urination throughout the day and night that often awake him. This patient has significant impairments in functioning and has continuous needs. The need for assistance with frequent toileting, turning, and repositioning will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved personal care aide of 24 hours per day, live-in is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living). The requested increase in personal care aide to 24 hours per day, split shift, is medically necessary.