Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase in Personal Care Services (PCS) to 24 hours a day (split shift), 7 days a week, for a total of 168 hours
The insurer denied the increase in PCS to 24 hours a day (split shift), 7 days a week, for a total of 168 hours.
The denial is overturned.

The patient is a female. She has several chronic medical conditions, including dementia. She lives alone. Denial of increase in personal care services (PCS) to 24 hours a day, split shift, 7 days a week, for a total of 168 hours is being appealed. The Plan approved PCS 24 hours a day, live-in, 7 days a week, for a total of 91 hours.

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, phone use, and shopping; maximal assistance with managing medications and lower body dressing; extensive assistance with bathing personal hygiene, upper body dressing walking, locomotion, and toileting; and limited assistance with bed mobility and eating. The patient has frequent bladder incontinence and infrequent bowel incontinence.

An appeal statement notes that the patient has deteriorating condition and requires assistance with all ADLs (activities of daily living). It notes that the patient's need for assistance with toilet transfer, bed mobility and locomotion prohibit the aide from receiving 5 hours of uninterrupted sleep. It notes that the hospice program recommends repositioning and turning every 2 hours.

An appeal letter states the patient needs around the clock monitoring and frequent assistance with transferring and ambulation. It states that she is incontinent throughout the night and requires frequent changes and positioning. She is offered small meals every few hours. Personal care logs show frequent assistance throughout the night with transfers, ambulation and toileting.

Yes, the increase in PCS to 24 hours/day, split-shift, is medically necessary.

PCS 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 PCS to 24 hours a day, split shift, 7 days a week, for a total of 168 hours is being appealed. The Plan approved PCS 24 hours a day, live-in, 7 days a week, for a total of 91 hours.

The patient has several chronic conditions including dementia. UAS evaluation completed shows the patient requires assistance with all ADLs. She has bowel and bladder incontinence. Appeal statements note that the patient's needs for frequent assistance with bed mobility and locomotion, as well as repositioning and turning every 2 hours, require 24 hours of continuous care. Personal care logs show the patient receiving frequent assistance with transfers, ambulation and toileting throughout the night. This patient has significant cognitive and physical impairments that impair daily functioning. The documentation provided shows the patient requires frequent assistance throughout the night that would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed increase in PCS to 24 hours a day, split shift, 7 days a week, for a total of 168 hours is medically necessary and appropriate.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.