Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ALS (amyotrophic lateral sclerosis).
Treatment: Increase HomeCare/ Personal Care HHC Services Hours From 56 Hours To 24 Hours Per Day (split shift) Pre-service.
The insurer denied the Increase HomeCare/ Personal Care HHC Services Hours From 56 Hours To 24 Hours Per Day (split shift) Pre-service.
The denial is partially overturned. 

The patient is a male with ALS (amyotrophic lateral sclerosis).  He is appealing denial of increase home care/personal care from 56 hours per week to 24 hours per day, split shift.  He lives alone.

UAS (Uniform Assessment System) evaluation performed shows the patient has independent cognition and functional status:  total dependence with housework; maximal assistance with meal preparation, managing medications, shopping, bathing personal hygiene, dressing, walking, locomotion, and toileting; extensive assistance with phone use, stairs, transportation, bed mobility, and eating.  He is reported to have an unsteady gait and inability to lift arms past navel level.  He has incontinence at night and waits until personal assistance service comes. He reports daily falls.  Compared to the previous UAS (Uniform Assessment System) evaluation three months prior, there had been a decline in personal hygiene, dressing, walking, locomotion, and toileting from extensive assistance to maximal assistance; and bed mobility and eating from limited assistance to extensive assistance.  A letter dated from the patient's provider notes the patient requires full time home care as he is dependent for all ADLs (activities of daily living). The letter notes that the patient is essentially paralyzed.

Yes, in part. The increase in personal care hours to 24-hour split-shift is medically necessary, in part.
Specifically, an increase in personal care hours to 24-hour live-in is medically necessary.

Medically necessary services are those which are: safe 
effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

An increase in personal care hours to 24-hour live-in is medically necessary, because it is consistent with generally accepted national standard of medical practice.

Continuous, or split-shift, personal care service 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 provider five hours daily of uninterrupted sleep during the aide's shift.  This patient has ALS (amyotrophic lateral sclerosis), which is a progressive condition.  He has been approved for 56 personal care hours per week.

UAS (Uniform Assessment System) evaluations performed show the patient requires assistance with all ADLs (activities of daily living) and personal care needs.  The most recent UAS (Uniform Assessment System) evaluation show a decline in functional status over two months to where the patient now primarily requires extensive to maximal assistance with ADLs (activities of daily living) and IADLs (instrumental activities of daily living).  A statement from the provider notes the patient is "essentially paralyzed." The patient has nighttime incontinence and has to wait for the aide for assistance.  This patient's condition is rapidly declining.  He has continuous needs that cannot be met with the approved 56 personal care hours per week.  Twenty-four hours per day is medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.  However, the documentation does not support the inability of the provider to obtain five hours daily of uninterrupted sleep during the aide's shift.  Therefore, the proposed increase in personal care hours to continuous care 24 hours per day, split shift is not medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.  At this time, a live-in 24-hour personal care worker is appropriate and medically necessary to meet this patient's needs.