Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness, history of falls, other abnormalities of gait and mobility, chronic pain, weakness and recent cholangiocarcinoma.
Treatment: Increase in Personal Care Services, Per 15 minutes to 24 Hours Per Day (Split Shift).

The insurer denied the Increase in Personal Care Services, Per 15 minutes to 24 Hours Per Day (Split Shift).  The denial is partially overturned.

The patient is an elderly female. Her conditions include dizziness, history of falls, other abnormalities of gait and mobility, chronic pain, and weakness. She was recently discharged from a SNF (skilled nursing facility) after having been diagnosed with urinary tract infection and cholangiocarcinoma. Denial of increase in personal care services to 24 hours per day (split shift) is being appealed. The plan approved 70 hours per week.
The patient's Uniform Assessment System (UAS) evaluation completed recently shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, bathing, lower body dressing, and toilet use; maximal assistance with managing medication, upper body dressing, toilet transfer, locomotion, and bed mobility; and extensive assistance with personal hygiene and eating. She has occasional bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in cognition and functioning with bathing, upper body dressing, bed mobility, locomotion, and eating. An appeal letter from the patient's provider notes that the patient had a recent decline in overall functioning. The patient has increased confusion and worsening incontinence. She needs assistance with ambulation and ADLs (activities of daily living). A statement from the patient's daughter notes that the patient has declined in the past two months. It notes that the patient needs 24-hour daily home care.

The requested Increase in Personal Care Services, Per 15 minutes to 24 Hours Per Day (Split Shift) is medically necessary, in part.

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. Denial of increase in personal care services to 24 hours per day (split shift) is being appealed. The plan approved 70 hours per week.

This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed recently shows she needs assistance with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in cognition and functioning with bathing, upper body dressing, bed mobility, locomotion, and eating. The patient has occasional bowel and bladder incontinence. Appeal statements support that the patient needs assistance with all ADLs. The information provided does to support that the patient has continuous care needs, such as frequent assistance with toileting, transfers, and turning/repositioning. The proposed increase in increase in personal care services to 24 hours per day (split shift) week is in excess of the patient's needs. However, the approved personal care services of 70 hours per week is insufficient to meet the patient's needs with ADLs (activities of daily living). Therefore, given the above, an increase in personal care services to 24 hours per day, live-in, is appropriate and medically necessary.