Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia.
Treatment: Personal care services, 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week.
The insurer denied Personal care services, 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week.
The determination is overturned.

This is a female patient with a medical history notable for Alzheimer's dementia. The patient was approved for 37.5 hours per week of personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week) and this request was partially denied by the health plan. The plan did approve an increase to 24 hours per day, 7 days per week (live-in) for a total of 91 hours per week.
The patient's physician provided a letter of medical necessity for this appeal. The patient was admitted to a skilled nursing facility for short term rehabilitation. Prior to that time, she lived by herself in an apartment and was independent in all activities of daily living (ADLs). However, she has had a significant decline and now requires assistance for many tasks including transferring, toileting, and bed mobility for pressure ulcers on her sacrum and heels. The physician requests continuous personal care due to her requirement for turning and repositioning every 2 hours to help with her pressure wounds.
A letter of support for this appeal was provided by a community advocate. The letter states that the patient is "totally bed bound and cannot reposition herself in bed." She is incontinent of both stool and urine. A live-in aide cannot get 5 hours of uninterrupted sleep at night due to the patient's ongoing personal care needs related to her toileting and repositioning in bed.
A Uniform Assessment System (UAS) was completed. The assessment was completed via teleconference. The patient's cognition was defined as moderately impaired. The patient was alert and oriented to person only. She had memory loss for short term, procedural, and situational tasks. She does not have the ability to direct her own care. From a functional standpoint, she required total dependence for meal preparation, housework, finances, medications, phone use, and shopping. For her ADLs, she required total dependence for locomotion and toilet use. She required maximal assistance for bathing, dressing lower body, walking, and toilet transfer. She required extensive assistance for hygiene, dressing upper body, bed mobility, and eating. She was reported to be frequently incontinent of urine and infrequently incontinent of stool. She uses pull-ups to manage incontinence care and is not capable of performing her own changes. At issue is the medical necessity of personal care services, 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week.

The requested health service/treatment of personal care services, 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week is medically necessary for this patient.
The patient is approved for live-in care which requires that her caregiver can get a full night's sleep, including the expectation of a minimum of 5 hours of uninterrupted sleep. This means that if the patient has personal care needs that preclude this 5 hours of rest for her aide, then split-shift care is medically appropriate. The patient has clearly documented personal care needs that are continuous around-the-clock and would preclude a 5 hour window of uninterrupted sleep. She has pressure ulcers of the sacrum and heels and needs assistance with turning and repositioning in bed every 2 hours throughout the day and night. She has incontinence of urine and stool and will require prompt diaper changes on an ongoing unscheduled basis. Failure to provide for her needs could result in worsening of skin breakdown and/or infection.