Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, diabetes, osteoarthritis
Treatment: Increase Personal Care Services to 24 Hours per 
Day, Split Shift (Two 12-Hour Shifts), 7 Days per Week, as a Nonmutual Case, for a Total of 168 Hours
The insurer denied: Increase Personal Care Services to 24 Hours per Day, Split Shift (Two 12-Hour Shifts), 7 Days per 
Week, as a Nonmutual Case, for a Total of 168 Hours
The denial is partially overturned.

This elderly female patient has multiple medical conditions including dementia, diabetes, obesity, hypertension, and osteoarthritis. The denial of an increase in personal care services to 24 hours per day, split shift (two 12-hour shifts), 7 days a week, as a nonmutual case, for a total of 168 hours is being appealed. The health plan approved 12 hours a day, 5 days a week (non-mutual) morning shift, for a total of 60 hours, and 12 hours a day, 5 days a week and 24 hours a day, 2 days a week evening and weekend shift (mutual), for a total of 108 hours.
A statement from the patient's provider notes the patient needs assistance separate from her husband with activities outside of the house, such as getting to doctor's appointments. She has 
difficulty walking and is a high risk for falls. The patient needs assistance with toileting due to incontinence. She requires a daily routine for chronic constipation. She gets up at night and 
calls because she is not feeling well. A statement from the daughter notes she is no longer able to provide care for her parents. Her mother's memory loss has progressed. Her mother needs assistance with activities of daily living. She notes that her parents have separate needs that cannot be managed by one aide. Her mother has had several falls due to being unsteady.

The increase in non-mutual services to 12 hours a day 7 days a week is medically necessary; however, an increase to 24 hours per day, split shift, is not medically necessary. 

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. This patient has multiple chronic conditions. The denial of personal care services (PCS) to 24 hours a day, split shift (two 12-hour shifts), 7 days a week, as a nonmutual case, for a total of 168 
hours is being appealed. The health plan approved 12 hours a day, 5 days a week (non-mutual), morning shift, for a total of 60 hours, and 12 hours a day, 5 days a week, and 24 hours a day, 2 days a week, evening and weekend shift (mutual), for total of 108 hours. The appeal statements indicate that the patient has progressive memory loss and needs assistance with activities of daily living. She does not have informal support. The appeal statements indicate medical necessity for an increase in personal care services because the mutual services with her husband are inadequate to meet her needs. However, the information provided does not support that this patient has continuous needs. Personal care services are not indicated for safety supervision. The proposed personal care aide services for a total of 168 hours per week, split shift, is not medically necessary. Mutual services should be discontinued as the patient's husband is recommended for split shift nonmutual care for a total of 168 hours per week. However, it is medically necessary to increase this patient's nonmutual services from the approved 12 hours a 
day, 5 days a week, to 12 hours a day, 7 days a week.