Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Personal Care - Home Health Care (HHC) Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split-shift)
The insurer denied Personal Care HHC Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split-shift).
The determination is upheld.

This is a female patient with a medical history notable for dementia and generalized weakness. The patient is approved for 24 hour live in personal care services. The patient and her care team requested an increase to 24-hour split shift services, and this request was denied by the health plan.
The patient's nurse practitioner provided a statement of medical necessity for the requested increase. The letter states that the patient's functional status has been rapidly declining. She is unable to toilet without assistance. Her dementia is advanced and she has delusions and is unable to direct her own care. She has urinary and fecal incontinence and requires multiple daytime and nighttime changes of soil diapers to prevent skin breakdown. Due to these extensive needs, the provider requests 24-hour split shift care.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented to person only intermittently. She was very forgetful and not able to direct her own care. Short-term and procedural memory were impaired. For her instrumental activities of daily living, she requires total dependence or maximal assistance for all. For her activities of daily living, she requires extensive assistance for bathing, personal hygiene, dressing up her body and lower body, and toilet transfer. She requires limited assistance for walking and locomotion. She requires supervision only for bed mobility. At issue is the medical necessity of Personal Care HHC Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split-shift). 

The requested health service of Personal Care HHC Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split-shift) is not medically necessary for this patient.
The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5 hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, there is a question as to whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.
There is insufficient evidence that the patient requires split shift personal care. There were no night time logs provided which demonstrate the frequency of personal care needs which would preclude an adequate rest period for a live-in aide. The patient does not require assistance with bed mobility according to the most recent assessment, and she has no pressure ulcers which would require turning and repositioning every two to three hours. The frequency of overnight toileting needs was not clearly defined. Therefore, there is insufficient evidence that the requested increase to split shift personal care is medically necessary for the patient.