Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Dementia with hallucinations, delusions & sundowners syndrome.
Treatment: Home Health Care/increase in personal care services to 24 hours a day split shift (2 12 hour shifts per day) 7 days a week a total of 168 hours a week.
The health plan denied the requested increase in personal care services to 24 hours a day split shift (2 12 hour shifts per day) 7 days a week a total of 168 hours a week. 
The health plan's determination is overturned.

This is a case review for a female with a medical history notable for Parkinson's dementia with hallucinations, hypertension, atrial fibrillation, and urinary incontinence. The patient is approved for 24 hours a day (live-in), 7 days per week of personal care services. The patient's care team requested an increase to 24 hour per day (2-12 hour split-shift personal care services).

A letter was provided from the physician who treated the patient in a skilled nursing facility following an inpatient hospitalization. The letter states that the patient uses a walker and can ambulate with the assistance of one person. She requires assistance going to and from the bathroom at all times "especially with the diagnosis of overactive bladder, assistance with hygiene/grooming care along with bathing and dressing." The letter states that she requires an increase in home health hours to ensure a safe transition back to the community.

A letter of support for this appeal was provided by the patient's neurologist. The letter requests continuous home health aide, but does not provide any further details or discussion of unmet personal care needs. Physician notes and physical therapy notes from her stay in skilled nursing were provided and reviewed in detail for this case review.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was reported to be oriented times three but able to direct her aide and provide consent. She requires maximal assistance for meal preparation, housework, shopping, and transportation. She requires extensive assistance for finances, medications, and phone use. For her activities of daily living (ADL's), she requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, bed mobility, and eating. She is frequently incontinent of urine and continent of stool.

The health plan's determination of medical necessity is overturned, in whole.

The requested health service/treatment of increase in personal care services to 24 hours a day split shift (2 12 hour shifts per day) 7 days a week a total of 168 hours a week is medically necessary for this patient.

The patient does live alone and relies on her home health aide for all functional tasks. The question at hand is whether live-in care or split-shift care is medically necessary. Live-in aides require the expectation of at least 5 hours of uninterrupted rest per night. If this cannot be granted, split-shift care is medically necessary.

This patient has personal care needs which would preclude a 5 hour window for her home health aide. The aide cannot be approved for safety monitoring alone; if the aide were simply to prevent night time behaviors, this would not be an allowable patient care function. However, the patient has urinary incontinence and evidence of skin breakdown. She needs prompt attention to toileting and changing as needed. Due to her dementia, she is not able to make her needs known. The physician who cared for her in the skilled nursing facility attested that an increase in hours was medically necessary to meet her needs. Similarly, her primary care physician attested to her needs for assistance when ambulating to the commode. Failure to promptly address these personal care needs could lead to further skin breakdown and/or infection.