Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase in personal care services, 24 hours a day split shift (2 12-hour shifts) 7 days a week, for a total of 168 hours 
The insurer denied: increase in personal care services, 24 hours a day split shift (2 12-hour shifts) 7 days a week, for a total of 168 hours 
The denial is overturned

The patient is a female with medical history notable for dementia, unsteady gait, back pain, and rectosigmoid adenocarcinoma. The patient is receiving 70 hours per week (10 hours per day, 7 days per week) of personal care services. The patient and her care team requested an increase to 24 hours daily (split shift) personal care services.

Over the course of the year, the patient's dementia began becoming progressively worse by subjective reporting. Additionally, due to her presumed rectal cancer, she has had increasing episodes of fecal incontinence which are occurring numerous times throughout the day and night. Despite medication to manage insomnia, the patient began awakening 3 or more times throughout the night. Some of these times are associated with episodes of incontinence. This has placed a large strain on the patient's granddaughter who works throughout the day and has been caring for the patient at night. During the weekends, other relatives help provide caregiver help throughout the night for the patient. Oxycodone has been used to help with nighttime fecal urgency. Per notes the "patient is constantly asking to use the toilet but doesn't remember she recently went." Due to this spectrum of medical needs, the treating physician recommended that the family appeal the request for split shift personal care services and felt that this was medically necessary.
A Uniform Assessment System (UAS) was completed. The patient was found to be oriented to person only, unable to make her needs known, and not able to call 911 for help. She does not always recognize her daughter. From a functional standpoint, she requires total dependence for meal preparation, housework, and managing finances. She requires maximal assistance for managing medications. She requires maximal assistance for nearly all activities of daily living (ADLs), including bathing, hygiene, dressing upper/lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for bed mobility and eating. She is frequently incontinent of both urine and stool. She uses pull-ups that require changing 10-15 times per day due to chronic diarrhea from her colon cancer. An Hours Evaluation for Paraprofessional Support (HELPS) assessment associated with this report recommended 69 hours per week to address her personal care needs.

The health plan's determination is overturned.

The requested increase in personal care services, to 24 hours a day split shift (2 12-hour shifts) 7 days a week, for a total of 168 hours is medically necessary for this patient.
The patient suffers from a presumed diagnosis of advanced colorectal cancer that causes frequent loose stools. She has urinary and fecal incontinence requiring diaper changes 10-15 times per day. She has advanced dementia and is unable to make her needs known. She has advanced functional debility and is unable to change a diaper on her own or toilet on her own. This patient has clearly demonstrated medical need for personal care services throughout the day and night. Her family has been filling in the gaps but may not be able to continue to do so due to work requirements.
This patient cannot go 14 hours a day without assistance. She needs to have pull-ups changed, on average, every 2 hours throughout the day and night. If she were to be left in soiled diapers, she would be prone to developing infections and/or skin breakdown, which would lead to rapid deterioration of her health.