Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/ Neuromuscular Disorder-Lou Gehrig's Disease/ Amyotrophic Lateral Sclerosis ALS
Treatment: Home Health Care-Personal Care Aid (PCA)
The health plan denied the PCA services as not medically necessary. 
The reviewer has overturned the health plan's determination in part.

This is a case review for a patient with medical history notable for amyotrophic lateral sclerosis. The patient is approved for 56 hours per week of personal care assistance. The patient and his care team requested an increase to 24 hours per day, 7 days per week split shift personal care, and the request was denied by the health plan. This denial is the subject under review.
The patient's neurologist provided a letter of support for this appeal. The letter states that the patient's diagnosis of ALS (Amyotrophic Lateral Sclerosis) is a degenerative neuromuscular disease that is chronic, life-limiting, and characterized by progressive paralysis and respiratory failure. The patient's symptoms are expected to worsen and there is no cure. The patient has lost upper and lower extremity function and is wheelchair bound. He requires total assistance with all personal care tasks. The patient currently lives alone.

A uniform assessment system (UAS) was completed. The patient was temporarily receiving additional help from his nephew, who is planning to return to Puerto Rico and the patient will then be living alone. The patient was alert and oriented with periods of forgetfulness. He is able to make his needs known. For his instrumental activities of daily living, the patient requires total dependence for stairs. He requires maximal assistance for transportation, shopping, housework, and meal preparation. He requires extensive assistance with finances, medications, and phone use. For his activities of daily living, he requires total dependence for walking in locomotion. He requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. He requires extensive assistance for dressing upper body and bed mobility. He requires limited assistance for hygiene and eating. He is noted to be bed bound. He is occasionally incontinent of urine, and he is continent of stool. He requires one to two pull-ups daily for incontinence care. The member most recently had a fall when his nephew was attempting to transfer him to the bedside commode. A task tool associated with the assessment recommended 48.25 hours per week to address his personal care needs.

The requested health service of Personal Care Assistance services, 24 hours per day 7 days per week (split-shift) has not been demonstrated to be medically necessary for this patient. The patient should be awarded 24 hour per day live-in personal care assistance services.
The patient has functional needs as a result of his neurologic condition. He is not able to complete any activities of daily living without personal care assistance. He requires assistance with locomotion, bathing, toileting, and dressing. His personal care needs are expected to be continuous and unscheduled throughout the day and occasionally at night as well. Therefore, it is medically necessary and reasonable for the patient to receive 24-hour live-in personal care services.
The request for 24-Hour split shift personal care services has not been demonstrated to be medically necessary for the patient. Split shift services are appropriate when a patient's care needs would preclude adequate rest for a live-in aide. These services are generally reserved for patients that have frequent episodes of incontinence or requirement for turning and repositioning due to an active pressure ulcer. There is no evidence that the patient has this requirement, or that a live-in aide would not be able to receive adequate rest. Therefore, the request for split shift personal care has not been demonstrated to be medically necessary.