Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Parkinson's disease
Treatment: Increase in Home Care/Personal Care HHC Level 2 Personal Care Services From 24 Hours Per Day (live-in) To 24 Hours Per Day (split shift)
The insurer denied the increase in home care/personal care HHC level 2 personal care services from 24 hours per day (live-in) to 24 hours per day (split shift).
The denial is overturned.

The patient is a female. Her conditions include dementia and Parkinson's disease. She lives alone. Denial of increase in home personal care assistance (PCA) services from 24 hours per day, live-in to 24 hours per day, split shift is being appealed.

The patient's Uniform Assessment Systems (UAS) evaluation completed shows severely impaired cognition and functional status requires total dependence with all IADLs (instrumental activities of daily living) and ADLs (activities of daily living) with exception of managing medications and eating, which require maximal assistance. She has no control of bowel and bladder.

A letter from the patient's daughter notes the patient's condition has deteriorated. She notes the patient needs assistance with ADLs as accounted for in the UAS evaluation. The letter notes the patient has become bedbound and nonverbal. She needs assistance with incontinence throughout day and night and aide is not able to get 5 hours uninterrupted sleep. The letter notes the patient needs to be positioned every 2 hours per her provider.

Night shift log shows the patient getting assistance approximately every 2 hours with transfers, toileting, and bed positioning.

A letter from the patient's provider notes the patient has advanced dementia and Parkinson's. She is confined to the bed. States she needs assistance with ADLs and requires turning and repositioning every 2 hours.

Yes, the requested increase in services to 24 hours/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 home personal care assistance (PCA) services from 24 hours per day, live-in to 24 hours per day, split shift, is being appealed.

The patient has conditions including dementia and Parkinson's disease. She lives alone. Per UAS evaluation complete, the patient requires total dependence with all IADLs and ADLs with exception of managing medications and eating, which require maximal assistance. She has bowel and bladder incontinence. Appeal statements note that the patient's condition has deteriorated, and she is now bedbound. She requires frequent assistance with transfer and toileting as well as turning and repositioning every 2 hours. This patient has significant progressive cognitive and physical impairments. She requires assistance throughout the day and night that do not allow for an aide to receive 5 hours of uninterrupted sleep. The approved live-in service is inadequate to meet the patient's needs for assistance with ADLs/IADLs. The proposed increase in personal care service to split shift is medically necessary and appropriate to meets this patient's needs.

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