Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic myelomonocytic leukemia
Treatment: Personal Care Services - 24 hours a day, 7 days a week, total for 168 hours per week (split-shift)
The insurer denied Personal Care Services - 24 hours a day, 7 days a week, total for 168 hours per week (split-shift).
The determination is partially overturned.

This is a female patient with a medical history notable for chronic myelomonocytic leukemia and traumatic brain injury. The patient is approved for 8 hours per day, 7 days per week (56 hours per week) of personal care services. The patient and her care team requested an increase to 24 hours per day (split-shift), 7 days per week (168 hours per week) and the request was denied by the health plan.
The patient's child provided a letter of support for this appeal. The letter states that the patient had been doing well until she began to decline. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient is unable to manage care by herself without constant assistance. She is totally dependent on others for activities of daily living. The physician requests 24-hours per day personal care for the patient.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient lives alone in an apartment building. Her cognition was minimally impaired. For her instrumental activities of daily living, she requires total dependence for shopping. She requires maximal assistance for transportation, stairs, phone use, finances, housework, and meal preparation. She requires extensive assistance for medications. For her activities of daily living, she requires maximal assistance for bathing, hygiene, and dressing. She requires extensive assistance for walking, locomotion, toilet transfer, toilet use, bed mobility, and eating. She was infrequently incontinent of urine and continent of stool. Incontinence episodes happen when she is not able to make it to the bathroom in time. A task tool associated with the assessment recommended 59 hours per week to address her personal care needs. At issue is the medical necessity of Personal Care Services - 24 hours a day, 7 days a week, total for 168 hours per week (split-shift) 

The services are medically necessary in part. The requested health service Personal Care Services - 24 hours a day, 7 days a week, total for 168 hours per week (split-shift) has not been demonstrated to be medically necessary for this patient. However, 24-Hour per day live-in care, 7 days per week, for a total of 91 hours per week is medically necessary.
The patient has several functional limitations as outlined by the Uniform Assessment System (UAS) and as attested by her physicians. She requires hands-on personal care assistance for all activities of daily living including ambulation and toileting. These tasks are expected to occur on a continuous and unscheduled basis throughout the day and night. The patient lives alone and does not have informal support. Therefore, 24-hour care is medically necessary and reasonable for the patient.
Split-shift personal care services are reserved for patients whose live-in care aide would not be able to receive adequate rest at night. There is insufficient documentation to demonstrate the medical necessity for split shift services. These services would typically be recommended if night care logs demonstrate the need for turning and repositioning to treat a pressure ulcer every 2 to 3 hours or to clean after episodes of incontinence.