Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis

Treatment: Personal Care Services, 24 hours a day, 7 days a week (split-shift), for a total of 168 hours a week

The insurer denied the Personal Care Services, 24 hours a day, 7 days a week (split-shift), for a total of 168 hours a week. The denial was reversed.   

This is an elderly female patient with a history of rheumatoid arthritis, recurrent pneumonia, deep vein thrombosis (DVT), and pulmonary embolism. It was reported that the patient had severe limitations to her mobility; she is bedbound and requires full assistance with all of her activities of daily living (ADLs) including medication administrations dues to her debilitating rheumatoid arthritis. She is a high risk for skin breakdown and requires frequent turning and positioning. She had been treated for several episodes of pneumonia likely due to extended hours lying in bed.  In the absence of the personal care assistant she is unable to drink which could result in dehydration and kidney injury. A request had been made for an increased in personal care assistance to 7 days a week, 24 hours a day.   

This review is for request for PCS, 24 hours per day, 7 days per week (split shift), total of 168 hours per week. The patient's personal care needs, as determined from this review, require continuous personal care services, 24 hours per day, split shift rather than 24 hours live-in. As per NYS regulations for live-in personal care aides, a person's care needs must be of such frequency that an aide can expect to have at least 5 uninterrupted hours of sleep per day. The patient has pressure ulcers (as per hospital records) and is at high risk for new pressure ulcers. The patient's physician will provide directions for frequency of turning and repositioning for pressure relief. It is reasonable to expect that it will be more frequent than every 5 hours. In addition, the patient may need repositioning for pain relief or assistance with taking fluids or prn medication at night (e.g. for pain).  Regarding toileting/incontinence care; in order to facilitate healing of current pressure ulcers and prevent the occurrence of incontinence associated skin injury, the patient needs prompt attention for incontinence. It is necessary for the aide to check the patient on a regular basis through the night and provide incontinence care when needed. 

Based on the information for this review, the patient's day/night care needs are of such frequency that a live-in aide could not expect to have 5 uninterrupted hours of sleep per day on a regular basis. Therefore, it is medically necessary to provide continuous personal care services 24 hours split shift to assist patient with all daily care needs including unscheduled ADL needs (toileting/incontinence care) and scheduled ADL needs (turning and repositioning for pressure relief) throughout the day and night.

Personal Care Services, 24 hours per day, 7 days per week (split shift), total of 168 hours per week is approved. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

Based on the above, the medical necessity for Personal Care Services, 24 hours a day, 7 days a week (split-shift), for a total of 168 hours a week is substantiated.  The insurer's denial is reversed.