Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/ Neuromuscular Disorder - Dementia.
Treatment: Home Health Care - Level 2 Personal Care Services, per 15 minutes increase to 24 hrs/day Split-Shift.

The health plan denied the home health care - Level 2 Personal Care Services, per 15 minutes increase to 24 hrs/day Split-Shift.  The health plan's determination is overturned.

The patient is a male with a medical history of dementia, pressure ulcers, coronary disease, spinal stenosis, and incontinence. He is currently receiving 24 hours per day (live-in) personal care services. His care team requested an increase to 24-hour split-shift personal care assistance which was denied by the health plan. The letter from his physician states that the patient is "completely unable to perform any activities...without Home Health Aid (HHA) help" and that that over the past couple of months his status has significantly deteriorated.

The patient's daughter provided a letter of support for this appeal. She describes that the patient care assistant has found the patient sliding off of his bed in the middle of the night, and that this occurred during what was supposed to be the 5-hour uninterrupted window. He has dementia and has had problems with nighttime wakening leading to wandering. He also has unpredictable urinary patterns and needs help at random, unscheduled times throughout the night. This problem is made worse by his prostate problem leading to more frequent urination.

Nursing notes describe a stage 2 pressure ulcer on the right buttock. Appropriate wound care was recommended.

A Uniform Assessment System (UAS) was completed. The patient's memory was impaired, consistent with his dementia diagnosis. The notes state: "decisions consistently poor or unsafe; cues/supervision required at all times." Family reported frequent hallucinations and nighttime awakening, which is associated with confusion, anxiety, and toileting needs. He was noted to have total dependence for meal preparation, housework, finances, and shopping and maximal assistance for medications. For activities of daily living, he requires total dependence for bathing and toilet use and maximal assistance for dressing his upper/lower body, locomotion, and toilet transfer. He requires extensive assistance for walking, bed mobility, and eating. He is incontinent of both bowel and bladder function daily and uses 8 diapers per day. He is completely reliant on others for toileting needs. He requires assistance for positioning in bed. He has a history of a pressure ulcer on the heel. A prior assessment was performed which shows that he has declined from both a cognitive and functional standpoint.
At issue is the medical necessity of the requested health service/treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (Split Shift).

The health plan's determination of medical necessity is overturned in whole.  The requested health service is medically necessary for this patient.

The patient has had a fairly precipitous functional and cognitive decline over the past year. The question at hand is whether or not his personal care needs can be met by a live-in aide who requires a minimum of 5 hours of uninterrupted sleep per night. The patient has personal care needs that exceed this threshold, and thus, he cannot be left alone for 5 hours overnight. The combination of fecal and urinary incontinence has led to a stage 2 ulcer on his buttocks. He needs prompt and frequent diaper changes to prevent worsening of this ulcer and to minimize the chances of infection. Leaving him in a soiled diaper for as many as 5 hours would be very detrimental to his health. Given his overnight toileting and positioning needs, it is medically necessary that he have continuous personal care services. His needs cannot be met with a 5-hour window to allow a live-in aide to sleep. Personal care services are not to be utilized for safety and supervision alone, but this patient has clear medical necessity for level 2 personal care.