Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gait Abnormality.
Treatment: Consumer Directed Personal Assistance Services, 24 hours a day, 7 days a week (split shift).
The insurer denied Consumer Directed Personal Assistance Services, 24 hours a day, 7 days a week (split shift).
The determination is overturned in part.

This is a female patient with a medical history notable for gait abnormality, chronic pain, and a recent fall with a hip fracture. The patient is approved for 12 hours per day, 5 days per week for a total of 60 hours per week of consumer-directed personal assistance services. The patient and her care team requested an increase to 24-hour per day split shift personal care, 7 days per week, for a total of 168 hours per week. The request was denied by the health plan, and this denial is the subject under review.
The patient's physician provided a letter of support for this appeal. The letter states that the patient's level of function has recently deteriorated, and she requires additional supervision and assistance to perform tasks. She recently had a hip fracture which contributed to this decline. She also had a transient ischemic attack in the setting of dehydration.

A Uniform Assessment System was completed. The patient lives alone in an apartment. She was alert and oriented times three. Recall was two out of three at 5 minutes and procedural memory was intact. The patient can direct her care and call for help in an emergency. For her instrumental activities of daily living, the patient requires total dependence on housework and stairs. She requires maximal assistance for meal preparation, shopping, and transportation. She requires extensive assistance with finances and medications. For her activities of daily living, the patient requires maximal assistance for walking, locomotion, and toilet transfer. She requires extensive assistance for bathing, dressing her upper body, toilet use, and bed mobility. She requires limited assistance for hygiene. She is continent of both urine and stool. There was no pressure ulcer present. A task tool associated with the assessment recommended 38 hours per week to address her personal care needs. At issue is the medical necessity of Consumer Directed Personal Assistance Services, 24 hours a day, 7 days a week (split shift).

In part. The requested health service of Consumer Directed Personal Assistance Services, 24 hours a day, 7 days a week (split shift) has not been demonstrated to be medically necessary for this patient. 24-hour per day (live-in) personal care, 7 days per week (total of 91 hours per week) is medically necessary for the patient.
The patient has extensive personal care needs as outlined in the assessment. She will require caregiver assistance for ambulation, transfers, toileting, and all other tasks. These tasks will be expected to occur on a continuous and unscheduled basis throughout the day and occasionally at night as well. Because of her need for toileting, the patient requires 24-hour care. Therefore, 24-hour live-in personal care, 7 days per week, for a total of 91 hours per week is medically necessary for the patient.
There is insufficient evidence that the patient requires 24 hours per day, two 12-hour split shift care, 7 days per week. There is no demonstrated evidence of care needs overnight such as incontinence care or turning and repositioning for an active pressure ulcer. No documentation would suggest that a live-in care aide would not be able to receive the minimum required rest. Therefore, the request for split shift care has not been demonstrated to be medically necessary for the patient. 24-hour live-in personal care, 7 days per week, for a total of 91 hours per week is medically necessary for the patient.