Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, legally blind, heart failure, osteoporosis with pathological vertebral fracture, irritable bowel syndrome with diarrhea, overactive bladder and dysphagia.
Treatment: Personal Care Worker, 7 days/week 24 hours/day split-shift continuous care by more than one person (The health plan approved 49 hours/week).
The insurer denied the Personal Care Worker, 7 days/week 24 hours/day split-shift continuous care by more than one person (The health plan approved 49 hours/week).
The denial is overturned, in part. 

The patient is a female has medical conditions including cognitive impairment, legally blind, heart failure, osteoporosis with pathological vertebral fracture, irritable bowel syndrome with diarrhea, overactive bladder and dysphagia. She lives alone. Denial of increase personal care worker (PCW) 7 days/week, 24 hours/day, split-shift, continuous care, is being appealed. The health plan approved 49 hours per week.

The patient was recently hospitalized after multiple falls, compression fracture, urinary tract infection and heart failure. She was transferred to rehab. She has had a decline in functional and mental status and vision impairment.

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework; extensive assistance with bathing, lower body dressing, walking, locomotion, toileting, and bed mobility; and limited assistance with personal hygiene, upper body dressing, and eating. The patient has occasional bladder incontinence.

The physician's order notes the patient requires 1 person assist with transfers and ambulation. She is at high risk for falls. Recommends 24 hours supervision.

An appeal statement notes the patient has multiple medical conditions that limit her capability to successfully complete ADLs (activities of daily living). The rehab facility has determined it is unsafe to return home without 24 hour continuous care.

Current rehab progress notes show that the patient is wheelchair bound. She is able to feed herself with set up. She requires 1 Assistance for all ADLs (activities of daily living) and transfers. Recommends 24 hour care to return home.

A letter from the patient's child notes that the patient has declined. States she needs 1 assist around-the-clock so she can return home.

A statement from the patient's aide has concerns with the care provided in the facility due to it being short-staffed.

Yes, in part. The increase in personal care worker to 24 hours/day, split-shift, is medically necessary, in part.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
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 PCW (personal care worker) 7 days/week, 24 hours/day, split-shift, continuous care, is being appealed. The health plan approved 49 hours per week.

The patient has several chronic conditions. She was recently hospitalized after multiple falls, compression fracture, urinary tract infection and heart failure. She was transferred to rehab. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). She has occasional bladder incontinence. Rehab progress reports show that the patient is wheelchair bound and requires 1 assist with all ADLs (activities of daily living). She can feed herself with set-up. This patient has significant physical impairments that have progressed. The approved PCW (personal care worker) 49 per week is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living)/IADLs (instrumental activities of daily living). However, the information does not support that the patient needs continuous care. The frequency of care at nighttime would not affect the aide's ability to get five hours daily of uninterrupted sleep during the aide's shift. The proposed increase in PCW (personal care worker) to 7 days/week, 24 hours/day, split-shift, continuous care is not appropriate. Increase is PCW (personal care worker) to 7 days/week, 24 hours/day, live-in is medically necessary to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care.