Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Increase in Personal Care Services from 70 hours to 24 hours per day (split shift). 
The insurer denied increase in Personal Care Services from 70 hours to 24 hours per day (split shift). 
The determination is overturned. 

This is a female patient with a medical history notable for dementia and incontinence. The patient is approved for 70 hours per week of personal care services. The patient and her care team requested an increase to 24-Hour per day split shift care, 7 days per week, for a total of 168 hours per week. This request was denied by the health plan. 
The patient's daughter notes that the patient lives alone and has dementia, a history of falls, and gait difficulty. She wakes up several times a night to use the bathroom. The patient requires assistance with walking, eating, and all activities of daily living. She does not have any informal support. The patient's daughter is requesting split shift care because the patient requires using the bathroom several times at night. 
Night time care logs were provided as part of this appeal. The logs demonstrate that overnight the patient requires toileting and diaper changes every 1 to 3 hours. She also requires some assistance with repositioning. There were no uninterrupted 5-hour periods without personal care needs during any period in the night. 
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient has had a severe cognitive decline and is not able to perform activities of daily living without assistance. The provider states that she has frequent night time care needs. They are recommending a split shift personal care for the patient.
A Uniform Assessment System (UAS) was completed. The patient's cognition was severely impaired. She was alert and oriented to person only and not self-directing. For her instrumental activities of daily living, the patient requires total dependence for essentially all activities. For activities of daily living, she requires maximal assistance for bathing, dressing lower body, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. The patient has stopped ambulating on her own. She no longer recognizes family and is completely unable to direct her care. She is dependent on others for transfers, toileting, and turning and repositioning. She is frequently incontinent of urine and wears Pull-Ups for incontinence care. There was no pressure ulcer present. At issue is the medical necessity of an increase in Personal Care Services from 70 hours to 24 hours per day (split shift).

The requested health service of increase in Personal Care Services from 70 hours to 24 hours per day (split shift) is medically necessary for this patient. 
The patient has advanced dementia, urinary incontinence, and severe mobility issues that have left her bed bound and wheelchair bound. Her personal care needs can be expected to be continuous and unscheduled throughout the day and the night. She will require continuous personal care assistance. The nighttime care logs demonstrate that a live-in personal care aide would not be able to receive sufficient rest at night. Therefore, the requested increase to 24 hour split shift care is medically necessary and reasonable for the patient. Failure to address her personal care needs could result in infection, injury, and/or skin breakdown.