Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, orthostatic hypotension, depression, metastatic breast cancer, and osteoarthritis
Treatment: Increase Personal Care Services Hours, 24 Hours a Day, 7 Days a Week (Split Shift), for a Total of 168 Hours per Week.
The insurer denied: Increase Personal Care Services Hours, 24 Hours a Day, 7 Days a Week (Split Shift), for a Total of 168 Hours per Week
The denial is upheld.

The patient is an elderly female. Her medical conditions include dementia, orthostatic hypotension, depression, metastatic breast cancer, and osteoarthritis. Denial of Increase personal care services hours, 24 hours a day, 7 days a week (split shift), for a total of 168 hours per week is being appealed. The health plan approved 91 hours per week.
The patient's Uniform Assessment System evaluation performed four months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and phone use; maximal assistance with managing medications; extensive assistance with bathing, lower body dressing, walking, locomotion, and toileting; limited assistance with personal hygiene, upper body dressing, and bed mobility; and supervision with eating. The 
patient has frequent bowel and bladder incontinence. She uses a walker for ambulation. An appeal letter notes the patient needs unscheduled assistance during evening and night with transferring, toileting, ambulation, medications, and cuing. She requires assistance with toileting every 2 hours. She has active psychosis and sundowning as a result of her dementia. Night logs show the patient requires supervision and redirection throughout the night. A letter from the patient's provider notes the patient has worsening delusions, disorganization, and agitation. She has poor gait and is unwilling to use assistive devices for ambulation. She has limited insight and is combative. She lives alone and has no informal support.

The Increase Personal Care Services Hours, 24 Hours a Day, 7 Days a Week (Split Shift), for a Total of 168 Hours per Week is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. 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 aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions, including dementia. She lives alone. Denial of Increase personal care services hours, 24 hours a day, 7 days a week (split shift), for a total of 168 hours per 
week is being appealed. The health plan approved 91 hours per week. Uniform Assessment System evaluation performed four months ago shows she requires maximal assistance with all ADLs (activities of daily living), except eating. She is incontinent of bowel and bladder. The appeal statements support the patient needs assistance with ADLs (activities of daily living). The appeal 
statements highlight the patient's cognitive impairment with psychotic component. She has limited insight, has delusions and agitation, and is combative. The night logs show the patient receiving redirection and supervision throughout the night. The night logs do not show the patient receiving continuous medical needs, such as toileting and turning/repositioning. The information is consistent with safety supervision. This patient's current cognitive status is unsafe. Personal care services are not indicated for supervision or when no tasks are being performed. The requested increase personal care services from 91 hours per week to 24 hours a day, 7 days a week (split shift), for a total of 168 hours per week is not medically necessary.