Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aortic stenosis, multiple myeloma, glaucoma status post corneal implants, anxiety and depression. 
Treatment: Increase Personal Care Aide Service Hours To 24 Hours A Day 7 Days A Week (split shift). 

The insurer denied: Increase Personal Care Aide Service Hours To 24 Hours A Day 7 Days A Week (split shift). 
The denial is overturned. 

The patient is an elderly female with aortic stenosis, multiple myeloma, glaucoma status post corneal implants, anxiety and depression, and need for noninvasive ventilation at night. The request is to increase personal care services from 12 hours a day, 7 days a week to 24 hours a day 7 days a week (split shift). 

This request was denied coverage by the health plan and the health plan subsequently upheld this denial. The rationale indicates that utilizing other measures such as physical therapy, transfer devices, and resources like Nursing Home Transition and Diversion Medicaid Waiver may better meet the patient's safety needs. The letter also notes that personal care services for companionship or safety supervision are not a covered service. 

An appeal letter is noted from the patient's daughter indicating that the patient requires continuous assistance and split shift, because the patient has nighttime needs, and the daughter is unable to be present in the evening. 

The requested Increase Personal Care Aide Service Hours To 24 Hours A Day 7 Days A Week (split shift) is medically necessary. 

Multiple letters from the patient's physicians support the medical need for 24 hour, 7 days a week Personal Care Aide Service due to multiple chronic medical comorbidities and "incontinence, cognitive decline, and lack of informal care giving support." The patient is noted to require assistance with multiple activities of daily living, including transferring, toileting, personal hygiene, and eating. While the possibility of a live-in aide is considered, the appeal documentation notes that this is not feasible, due to the frequent nighttime needs of this patient. A log spanning two weeks notes that the patient has multiple night time awakenings requiring assistance for bathroom use, transfers from bed, assistance with oral hydration. Based on the frequency of these needs, it is not clear that a live-in aide would receive the standard requirement of 5 hours of uninterrupted sleep per night (Nisbet et al 2019). 

The health plan notes that resources such as Nursing Home Transition and Diversion Medicaid Waiver may better meet the patient's needs. However, it is not clear that the available services through this program (for example Assistive Technology (AT), Community Integration Counseling (CIC), Community Transitional Services (CTS), Congregate and Home Delivered Meals, Environmental Modifications (E-Mods), Home and Community Support Services (HCSS), Home Visits by Medical Personnel, Independent Living Skills and Training Services (ILST), Moving Assistance, Nutritional Counseling/Educational Services, Peer Mentoring, Positive Behavioral Interventions and Supports (PBIS)) are fully meant or able to adequately address the patient's documented night-time needs. 

Thus, the requested increase to 24 Hours A Day 7 Days A Week (split shift) care is medically necessary.