Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, neuropathic pain, hypertension. 

Treatment: 168 hours/week, 12 Hours x 2 x 7 days split shift. 

The insurer denied coverage for 168 hours/week, 12 Hours x 2 x 7 days split shift. 

The denial is overturned. 

This patient with history of dementia, neuropathic pain, hypertension, hyperlipidemia, and history of cerebrovascular accident/transient ischemic attack.  The patient was noted to have right-sided hemiparesis, expressive aphasia, delusions, chronic kidney disease, and kyphosis. 

On the most recent UAS (uniform assessment system) the provider noted that the patient had impaired cognition and aphasia secondary to cerebrovascular accident and dementia. She was unable to transfer without assistance. She had neurological deficits that were permanent. She had advanced dementia, aphasia, and was unable to perform activities of daily living. She was not able to request assistance when needed. She ambulated with a rolling walker and assist of 1. Her medications were administered by the staff.  She was unable to go to the bathroom without assistance. She was unable to transfer without assistance. She was unable to bathe or toilet without assistance. She was unable to follow instructions. 

Per the cited references, to qualify for a split shift or continuous personal care services, the patient must require uninterrupted care by more than one personal care aide for more than 16 hours in a calendar day with tasks such as toileting, walking, transferring, turning, or positioning with such frequency that an in-living 24-hour personal care aide would not be able to obtain on a regular basis 5 hours daily of uninterrupted sleep during the 8-hour sleep. In this case, the patient had a history of dementia. She was unable to verbalize goals of care. Her cognition was impaired. Her decisions were consistently poor or unsafe. She had episodes of wandering in the past. She had a history of difficulty walking and falling. The provider noted that the patient had impaired cognition and aphasia secondary to a cerebrovascular accident and dementia. She was unable to transfer without assistance. She had advanced dementia, aphasia, and was unable to perform activities of daily living. She was not able to request assistance when needed.  She was unable to go to the bathroom without assistance. She was unable to transfer without assistance.  She was unable to bathe or toilet without assistance. She was unable to follow instructions. It is usual for nighttime toileting needs to increase as a person ages.  For patients with dementia, their nighttime behaviors can be unpredictable.  It was also noted that the patient was frequently incontinent. The caregiver at night is medically necessary to aid with activities of daily living should the patient awaken to toilet. They are also needed to monitor for episodes of incontinence which could lead to skin breakdown if not addressed promptly. Fall prevention should be a priority for the patient given her history of falls. She would require assistance with walking to and from the bathroom as well as with toileting at night. In a patient with dementia, the wake schedule is unpredictable. She would require full 24-hour coverage to address her nighttime needs. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for homecare/ Personal Care HHC - Level 2 Personal care Services, 168 hours/week, 12 hours x 2 x 7 days split shift is overturned. Medical Necessity is substantiated.