Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: increase in Personal Care Worker (PCW) services from 7 days per week, 24 hours per day, live-in; 91 hours per week to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week.
The insurer denied an increase in Personal Care Worker (PCW) services from 7 days per week, 24 hours per day, live-in; 91 hours per week to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week.
The determination is upheld.

The patient is a male with a medical history that is notable for dementia. The patient is approved for 24-hour live-in PCW (Personal Care Worker) services, 7 days per week (91 hours per week). The patient and his care team requested an increase to 24 hours per day (212-hour split-shift), 7 days per week (168 hours per week) and this request was denied by the health plan. This denial is the subject under review.
The patient's daughter provided a letter of support for this appeal. The letter states that the patient has been wandering in his house at night and disconnecting his catheter. Therefore, the patient's aides have not been able to get the required amount of rest during their shifts. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient is unable to sleep at night. He wakes up and walks around the apartment and requires supervision. The physician also states that the aides are not getting the required rest period each night.
The patient's urologist provided a letter of support for this appeal. The letter states that the patient has a history of prostate cancer and urinary retention. He requests that the patient be provided with assistance in changing his bag every two or three hours.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in-person. The patient's cognition was moderately impaired. A mini-mental state examination (MMSE) score was 11 out of 30, consistent with severe cognitive impairment. For his Instrumental activities of daily living (IADL's), he requires total dependence or maximal assistance for all. For his activities of daily living (ADL's), he requires maximal assistance for bathing and dressing lower body. He requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. He requires limited assistance for bed mobility and eating. He has a chronic indwelling urinary catheter. He is occasionally incontinent of stool (less than daily). Compared to a prior UAS (Uniform Assessment System), he showed a decline in functional status.
Personal Care Worker night shift logs were provided for review. The logs show that the patient does not sleep. He frequently comes out of his room and has to be reminded to go back to bed. There are no documented personal care functions during the night shift.

The requested health service of increase in Personal Care Worker (PCW) services from 7 days per week, 24 hours per day, live-in; 91 hours per week to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week has not been demonstrated to be medically necessary for this patient.
The patient has advanced dementia. He requires assistance with all ADL's (activities of daily living) and IADL's (Instrumental activities of daily living). He is approved for 24-hour care with a live-in aide, but the question at hand is whether or not he requires personal care assistance continuously throughout the night which would preclude the aide's ability to get 5 uninterrupted hours of sleep. There is no clear evidence that the patient has personal care needs that need to be tended to overnight. He does not require toileting as he has an indwelling catheter and does not require turning and repositioning. It does appear that he has behaviors that require management overnight, but personal care hours are not approvable for supervision and safety only in the absence of a personal care function. Therefore, the medical necessity for increased personal care worker hours has not been clearly demonstrated.
 
The health plan's determination of medical necessity is upheld in whole.