Diagnosis: Arthritis
Treatment: Increase Personal Care Assistance (PCA) from 24 hours/day, 7 days/week, live-in to 24 hours/day, 7 days/week, split shift
The insurer denied the increase in PCA from 24 hours/day, 7 days/week, live-in to 24 hours/day, 7 days/week, split shift.
The denial is upheld.

The patient is a female with medical history notable for psoriatic arthritis, osteoporosis, history of bilateral hip replacement, history of bilateral shoulder replacement, history of right knee replacement, gait disorder (wheelchair bound), chronic pain, urinary incontinence, and chronic hypercapnic respiratory failure. The patient currently receives 24 hour live-in personal care. The patient and her care team requested an increase to 24 hour split-shift personal care and this request was denied by the insurance company. This denial is the subject under review.

A letter of support for this appeal was provided by the treating physician's office. This appeal states that the patient has needs for medical care that have been preventing the necessary 5 hour window of uninterrupted sleep for the personal care aide, causing them to be "up all day and most of the night and are exhausted." They therefore requested that the insurance company "fulfill the patient's request in order to avoid exacerbation of his/her medical condition(s)." No specific details regarding unmet medical needs were cited.

A recent office visit note from the treating physician was available for review. This note discusses the need for home health care. Per the notes: "Patient is wheelchair dependent and requires assistance with all of her activities of daily living (ADLs) at this time. Patient notes that her home attendants rotate in 24 plus (+) hour shifts (live-in) but has been having issues with care at night as she notes that her home attendants are usually tired from helping her all day and can be difficult to get the help she needs in a timely manner as her home attendants have sometimes fallen asleep secondary to exhaustion."

The health plan's determination is upheld.

The requested health service/treatment of Personal Care Assistance from 24 hours/day, 7 days/week, live-in to 24 hours/day, 7 days/week, split-shift has not been demonstrated to be medically necessary for this patient.

The question at hand is whether or not this patient's care needs can be met by a 24-hour live-in attendant, who would require a minimum of 5 hours of uninterrupted sleep at night. If the patient has medical needs that would go unmet during this 5 hour period, they would qualify for split-shift. The patient does not have any evidence of pressure ulcer and no request from the treating physician for period turning and positioning. She has urinary incontinence, but has some control present and uses incontinence supplies. There was no statement regarding incontinence issues being the cause of her home health aide being unable to sleep. It is unclear from the documentation what health needs, if any, are preventing the aide from being able to sleep. Therefore, there is no established medical necessity for split-shift services.