Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced dementia
Treatment: Personal Care Aide (PCA) 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (spilt shift) a total of 168 hours per week 
The insurer denied: Personal Care Aide (PCA) 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (spilt shift) a total of 168 hours per week 
The denial is: Overturned

The patient is a female with medical history notable for advanced stage dementia. The patient was approved for 52.5 hours per week of personal care assistance. The patient and her care team requested an increase to 168 hours per week (2-12 hour per day split-shift) personal care assistance. This request was partially denied by the insurance plan, who did approve an increase to 24 hour Personal Care Aide (PCA) live-in. This denial is the subject under review.

A letter of medical necessity for this appeal was provided by the patient's physician. The physician reports that the patient has extremely poor functional status, advanced dementia, dysphagia with total loss of appetite, and nighttime behavioral disturbance. She is severely malnourished with a body mass index (BMI) of 15.4 and has a feeding tube since her hospitalization several months ago; records from this hospitalization were provided for review. She has urinary and fecal incontinence and wears diapers which require assistance for changing. Her physician attested that her functional needs are such that she medically requires split shift personal care to maintain her health and prevent complications from her illnesses.
A letter of support for this appeal was provided by a patient advocate. The letter states that due to the patient's nighttime behavioral disturbances, the patient's aides are unable to sleep at night. She is frequently yelling, requiring repositioning, or needing a change of diaper.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented times one with severely impaired cognition. She requires total dependence for most Instrumental activities of daily living (IADLs) including meal preparation, housework, managing finances, managing medications, stairs, and equipment management. She requires maximal assistance for phone use and transportation. For her activities of daily living (ADLs), she requires total dependence for all (bathing, hygiene, dressing, walking, locomotion, toilet transfer, toilet use, bed mobility, eating). She is frequently incontinent of stool and urine and uses diapers to manage incontinence. Compared with a prior UAS, she showed a decline in functioning in nearly all domains.

The health plan's determination is overturned.

The requested health service/treatment of Personal Care Aide (PCA) 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (spilt shift) a total of 168 hours per week is medically necessary for this patient. The patient has advanced dementia and is reliant on others for all activities of daily living and instrumental activities of daily living. She is incontinent of urine and stool. She requires assistance with repositioning in bed at night.
For this patient's care needs, it is not likely that she can consistently go 5 hours without human intervention. The letter from the patient advocate attests that the patient is calling out throughout the night for assistance; her needs are of a personal care nature, for repositioning or diapering. Furthermore, the physician attested to the need for increased personal care hours to attend to her needs. She requires prompt changing of soiled diapers to preserve skin integrity and prevent infections. Therefore, it is medically necessary for the patient to receive split-shift services.