Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Heart disease, hypertension, depression, peripheral arterial disease, right eye blindness, macular degeneration, and spinal stenosis
Treatment: Increase Personal Care Service Hours to 24 Hours A Day Seven Days a Week (Split Shift)
The insurer denied: Increase Personal Care Service Hours to 24 Hours A Day Seven Days a Week (Split Shift)
The denial is partially overturned.

This elderly female patient has multiple chronic conditions, including heart disease, hypertension, depression, peripheral arterial disease, right eye blindness, macular degeneration, and spinal stenosis.  She is status post hospitalization after a fall that resulted in three broken ribs. The patient is appealing denial of increase in personal care service hours to 24 hours a day, seven days a week (split shift). The health plan approved 12 hours a day, seven days a week for a total of 84 hours a week. 

The patient's Uniform Assessment System evaluation completed recently shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, lower body dressing, walking, locomotion, and toileting; extensive assistance with managing finances and medications, phone use, personal hygiene, bed mobility, and eating. She has bladder incontinence.

The proposed increase to personal care service hours to 24 hours a day, seven days a week (split shift) is not medically necessary; however, personal care service hours to 24 hours a day, seven days a week, live-in 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.

This patient has multiple chronic medical conditions. She was recently hospitalized after a fall. She is appealing denial of increase personal care service hours to 24 hours a day, seven days a week (split shift). The health plan approved 12 hours a day, seven days a week, for a total of 84 hours a week. The request was denied by the plan because the plan does not provide aide services for safety supervision, companionship, or when no tasks are being done. The patient's Uniform Assessment System evaluation completed recently shows the patient needs assistance with all activities of daily living (ADLs). She has bladder incontinence. There is no information provided to support that the patient requires continuous care. The proposed increase to personal care service hours to 24 hours a day, seven days a week (split shift), is not medically necessary. However, the approved 84 hours per week is insufficient to meet the patient's needs. Based on the patient's current functional status, personal care service hours to 24 hours a day, seven days a week, live-in is medically necessary.