Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, urinary incontinence, multiple urinary tract infections, osteoporosis, and metastatic basal cell carcinoma.
Treatment: Increase Personal Care Services to 24 Hours/Day
Split Shift (two 12-hour shifts) 7 Days/Week, for a total of 168 Hours.
The insurer denied the Increase Personal Care Services to 24 Hours/Day
Split Shift (two 12-hour shifts) 7 Days/Week, for a total of 168 Hours.
The denial is overturned.

The patient is a male. He has conditions including Alzheimer's dementia, urinary incontinence, multiple urinary tract infections, osteoporosis, and metastatic basal cell carcinoma.  His daughter is appealing denial of PCS (personal care service) 24 hours per day, split shift, 168 hours per week.  He has been approved for 49 hours per week.

UAS (Uniform Assessment System) evaluation performed shows moderately impaired cognition and functional status: total dependence with meal preparation, and housework; maximal assistance with managing finances, shopping, and transportation; extensive assistance with managing medications, phone use, equipment management, bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility; and limited assistance with eating.  The patient uses a wheelchair and walker for ambulation with contact guard indoors.  He is occasionally incontinent of bladder and infrequently incontinent of bowel.  He is status post right hip fracture after a fall.  He uses oxygen as needed for shortness of breath.

Letter from the patient's provider states that the patient has advanced dementia and is dependent for ADLs (activities of daily living). The letter further notes that the patient gets up multiple times during the night to use the bathroom.  The letter notes that the patient uses undergarments and needs to be changes several times during the night.  The provider is recommending 24 aide in 12 hour shifts.

A letter from the patient's daughter notes that the patient does not remember to use the walker. She notes needs for assistance with ADLs (activities of daily living) as accounted for in the UAS (Uniform Assessment System) evaluation.

Yes, the Increase Personal Care Services to 24 Hours/Day Split Shift (two 12-hour shifts) 7 Days/Week, for a total of 168 Hours is medically necessary.
Medically necessary services are those which are:
1) safe. 2)effective. 3) generally accepted national standard of medical practice. 4) not provided primarily for convenience of the patient or the practitioner. 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested health service is medically necessary, because it is consistent with generally accepted national standard of medical practice.

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 provider five hours daily of uninterrupted sleep during the aide's shift.

This patient has multiple chronic conditions, including dementia. He was recently hospitalized after a fall that resulted in a right hip fracture. The patient's daughter is appealing denial of PCS (personal care service) at 24 hours per day, split shift. He has been approved for 49 hours per week.

UAS (Uniform Assessment System) evaluation performed shows the patient requires assistance with all ADLs (activities of daily living)/IADLs (instrumental activities of daily living). Other than eating, the level of assistance needed is from extensive assistance to total dependence. He has a walker and wheelchair for ambulation, which requires contact guard assistance. The patient's provider notes that the patient needs assistance with ADLs (activities of daily living) and incontinence care. The provider states that the patient has incontinence several times during the night and requires undergarment change. The patient has difficulty ambulating to the bathroom and often forgets his walker. He is a fall risk because he forgets to use his walker. He is incontinent of bladder and has demonstrated the need for assistance with ambulation/transfers for toileting during day and night. This patient requires a significant assistance with ADLs (activities of daily living) and IADLs (instrumental activities of daily living). This patient has continuous needs that cannot be met with the approved PCS (personal care service) 49 hours per week. The proposed increase in PCS (personal care service) to 24 hours per day, split shift is medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.