Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Alzheimer's disease, COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), CAD (coronary artery disease), and asthma. 
Treatment: Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift)
The insurer denied the Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift).
The denial is overturned.

The patient is an elderly female. She has multiple conditions including dementia, Alzheimer's disease, COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), CAD (coronary artery disease), and asthma. Denial of increase in personal care level 2 services from 24 hours per day (live -in per diem) to 24 hours per day (split shift) is being appealed.

Uniform Assessment System (UAS) evaluation shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, shopping, bathing, lower body dressing, locomotion, and toilet use; maximal assistance with personal hygiene, upper body dressing, walking, toilet transfer, and eating; and extensive assistance with bed mobility. The patient has occasional bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline with managing finances, bathing, personal hygiene, lower body dressing, locomotion, and eating.

An appeal letter indicates the patient has multiple chronic conditions and functional impairments as well as visual hallucinations and memory problems. She confuses day and night. The letter notes that the patient has unpredictable needs for assistance with toileting, ambulation, and transfers. Her grandson provides assistance with toileting five to six times per night.

The requested increase in Personal Care Level 2 Services from 24 Hours Per day (live -in per diem) to 24 Hours Per Day (split shift) is 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. Denial of increase in personal care level 2 services from 24 hours per day (live -in per diem) to 24 hours per day (split shift) is being appealed.

This patient has multiple chronic conditions, and is bed and wheelchair bound. Uniform Assessment System (UAS) evaluation shows the patient requires assistance with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation previously, there has been a decline with managing finances, bathing, personal hygiene, lower body dressing, locomotion, and eating. The patient is incontinent of bowel and bladder. The appeal statement reports that the patient has nighttime needs that include assistance with toileting five to six time per night. This patient 's need for frequent toileting throughout the night support her continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved personal care 24 hours per day (live -in per diem) is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The requested increase to 24 hours per day (split shift) is medically necessary.