Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Increase in Personal Care Aide Level 2 hours to 12 hours per day split shift for total of 168 hours per week. 
The insurer denied increase in Personal Care Aide Level 2 hours to 12 hours per day split shift for total of 168 hours per week.  

The denial is upheld.

The patient is a female with a past medical history significant for dementia with behavioral disturbance, gait abnormality, scoliosis, sleep wake cycle disorder, B12 deficiency, compression fracture of lumbar (L)2 and multinodular goiter.

This review is from the medical necessity of personal care level 2 aide services, 12 hours per day  7 days a week for a total of 168 hours per week split shift. The services were denied based on lack of medical necessity.

No, the requested health service/treatment of Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (Split Shift) a total of 168 hours per week is not medically necessary for this patient.

The patient is a female with a past medical history significant for dementia with behavioral disturbance, gait abnormality, scoliosis, sleep wake cycle disorder, B12 deficiency, compression fracture of L2 (second lumbar spinal vertebra) and multinodular goiter. She has extensive cognitive deficits from dementia and functional disability due to her age and other underlying medical problems. She is dependent on others for all of her Instrumental activities of daily living (IADLs) and activities of daily living (ADLs). There was a notation in the physician progress note stating that the patient is able to walk with contact guard. She is currently approved for 24 hour a day live in service.

Services were denied stating the patient does not meet criteria. Stating that many of her abilities to perform physical functioning, activities of daily living state the same since her prior assessment. This includes dressing lower body, walking, transfer to the toilet, toilet use, eating, meal preparation, medication management and ordinary housework. The Uniform Assessment System (UAS) did not support the need for additional nighttime hours.

Physician statement was reviewed. UAS state of New York assessments were reviewed. 
There was a notation of progress note stating that the patient should be turned every 2 hours to prevent bedsores. There is no noted or documented bedsores. From the review of the literature data on preventive repositioning versus repositioning as a treatment modality for a decubitus ulcer is somewhat imprecise in regarding to the timing and the frequency of turning as reported in the following Cochrane study.  Therefore, without definitive data to support that 2 hour versus 6 hour turning is more effective, it cannot be recommended. 

"In the study, participants were randomized between second hourly and third hourly repositioning on a standard hospital mattress and fourth hourly and sixth hourly repositioning on a viscoelastic foam mattress. This study was also at high risk of bias, and the results were imprecise (relative risk [RR] 0.90, 95% confidence interval [CI] 0.69 to 1.16; and RR 0.73, 95% CI 0.53 to 1.02 respectively)."

The time allotted to perform the services according to the UAS and other documentation provided are adequate to meet the patient's needs. There is no documented nocturnal need that cannot be provided with available 24 hour live-in aide services. There are no active bedsores or other medical treatments which require specific treatment during the nocturnal hours. Specifically, there is no documentation why the aide cannot be available to meet her needs. There is no nighttime log to document specific nocturnal needs. There is no log or other statement to know why an aide cannot get adequate sleep, defined as 5 hours of interrupted sleep in a 24 hour period.