Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia.
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day 7 days per week; 12 hours per day 7 days per week a total of 168 hours per week (split shift).
The insurer denied Personal Care Aide (PCA) Level 2: 12 hours per day 7 days per week; 12 hours per day 7 days per week a total of 168 hours per week (split shift).
The determination is overturned.

The patient is a female with a medical history notable for Alzheimer's dementia and incontinence. The patient is approved for 24-hour live-in personal care assistance. The patient and her care team requested an increase to 24-hour split-shift care, and this request was denied by the health plan.
The patient's daughter provided a letter of support for this appeal.  The patient had a recent 10-day hospitalization secondary to a urinary tract infection. She states that this was a direct result of the lack of personal care received while the live-in care aide was receiving their required rest. Without care overnight, the patient spends several hours in a diaper with urine and feces; the patient is physically unable to diaper without assistance. 
The patient's neurologist notes that the patient is dependent on others for all activities of daily living. She has progressive and worsening dementia. The physician recommends 12-hour split shift care to promote her well-being at night.
The patient's physician notes that the patient had a fall. She has had recurrent urinary tract infections associated with urinary incontinence and needs frequent diaper changes every two to three hours overnight. This will assist in preventing infections and pressure ulcers. Because of these personal care needs, the physician recommends split-shift personal care.
A Uniform Assessment System (UAS) was completed. The patient lives alone in a two-bedroom apartment. She was alert and oriented to person and place only. Her short-term and procedural memory were not intact. She is not able to direct her care or call for help in an emergency. For her instrumental activities of daily living, the patient requires maximal assistance or total dependence for all. For her activities of daily living, the patient requires maximal assistance for essentially all. She requires extensive assistance for bed mobility. She is frequently incontinent of both urine and stool. There was one fall in the previous 30 days. At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 12 hours per day 7 days per week; 12 hours per day 7 days per week a total of 168 hours per week (split shift).

The requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day 7 days per week; 12 hours per day 7 days per week a total of 168 hours per week (split shift) is medically necessary for this patient.
The patient is approved for live-in personal care. The request is for split-shift personal care. Live-in personal care aides are present for 24 hours but must receive adequate rest each day, including the expectation of a minimum of 5 hours of uninterrupted rest per day. If a patient has personal care needs that would preclude this required rest, then split shift care is medically indicated.
The patient's personal care needs have been demonstrated to be continuous and unscheduled throughout the day and tonight. She has incontinence of stool and urine and requires prompt changing of incontinence care products. This has led to pressure ulcers and urinary tract infections in the past, which are evidence of unmet personal care needs. The requested increase in personal care is therefore medically necessary for the patient.