Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, Falls
Treatment: Personal care Aide Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (Split shift) - total 168 hours per week
The insurer denied Personal care Aide Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (Split shift) - total 168 hours per week.
The determination is overturned.

This is a female patient with a medical history notable for Alzheimer's dementia, overactive bladder, and history of falls. The patient is approved for 7.5 hours per day, 7 days per week (52.5 hours per week) of personal care aide services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift care), 7 days per week (for a total of 168 hours per week) and the request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has been in long-term placement. The patient is alert and oriented to person and place only with forgetfulness and confusion. She requires assistance for most activities of daily living. The patient's primary physician provided a letter of support for this appeal. The letter states that the patient requires hands on assistance for toileting, transfers, ambulating, and turning/repositioning. She lives alone and has no formal or informal supports.
Night time care logs were provided for review. The overnight logs detail personal care tasks being performed every 1-2 hours. These include frequent turning and repositioning, toileting, diaper changes, and changing clothes/sheets after incontinence episodes.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted at the skilled nursing facility. The patient had moderately impaired cognition. She was alert and oriented to person and place. She had periods of forgetfulness. Short term and procedural memory was disrupted. For her Instrumental activities of daily living (IADLs), she requires total dependence or maximal assistance for all. For her ADLs, she requires total dependence for bathing and locomotion. She requires maximal assistance for hygiene, dressing, walking, toilet transfer, and toilet use. She requires extensive assistance for bed mobility. She is frequently incontinent of urine and continent of stool and uses diapers for incontinence care. There was no pressure ulcer present at the time of the evaluation.
At issue is the medical necessity of Personal care Aide Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (Split shift) - total 168 hours per week.

The requested health service Personal care Aide Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (Split shift) - total 168 hours per week is medically necessary for this patient.
The patient requires hands-on personal care assistance for all activities of daily living. She requires help with transfers, toileting, ambulation, and turning/repositioning in bed. She previously had numerous falls and developed a pressure ulcer, which are evidence of unmet personal care needs. Given her dementia and incontinence, her personal care needs are expected to be continuous and unscheduled throughout the day and night. The caregiver night logs reflect that the patient requires assistance every 1-2 hours overnight. Due to the continuous nature of her care needs, split-shift care is medically necessary and appropriate for the patient. Failure to provide for her personal care needs could result in additional falls and/or skin breakdown.