Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: increase to 24 hours per day live-in or split-shift, 7 days per week, for a total of 168 hours per week
The insurer denied increase to 24 hours per day live-in or split-shift, 7 days per week, for a total of 168 hours per week.
The determination is overturned.

This is a female patient with a medical history notable for dementia, incontinence, and wheelchair-bound status. The patient is approved for 9 hours per day, 7 days per week for a total of 63 hours per week of personal care services. The patient and her care team requested an increase to 24 hours per day live-in or split-shift, 7 days per week, for a total of 168 hours per week. 
The patient's physician assistant provided a letter of support for this appeal. The letter states that the patient has advanced cognitive decline. She has an unstable gait due to a chronic lower extremity swelling. Her cognitive function and condition have declined significantly over the past 6 months. She requires cueing for all activities of daily living. She requires overnight care for frequent turning and positioning as she is prone to skin breakdown. Therefore, the provider recommends 24-hour care for the patient.
A Uniform Assessment System (UAS) was completed. The patient was living with her daughter at the time. The patient's cognition was moderately impaired; she was alert and oriented to person and occasionally to place. She is not able to direct her own care and was not safe if left alone. For her instrumental activities of daily living, the patient requires total dependence for meal preparation, housework, finances, phone use, stairs, shopping, and transportation. She requires maximal assistance for medications. For her activities of daily living, she requires total dependence for bathing and locomotion. She requires maximal assistance for hygiene, dressing upper body, walking, toilet transfer, toilet use, bed mobility, and eating. She is frequently incontinent of both urine and stool and uses Pull-Ups for incontinence care. She calls out during the night and is up to 6 to 7 times throughout the night asking for assistance with toileting and other personal care tasks. She had one fall in the month prior to the assessment.
Overnight care logs were provided. The care logs demonstrate that the patient requires personal care assistance every 1-2 hours throughout the night. At issue is the medical necessity of Personal Care Services, 24 hours a day live-in or split shift (two 12-hours shift), 7 days a week, totaling 168 hours.

The requested health service of Personal Care Services, 24 hours a day split shift (two 12-hours shift), 7 days a week, totaling 168 hours is medically necessary for this patient.
The patient relies on caregiver assistance for all activities of daily living. She is not able to direct her own care and her care is complicated by advanced dementia. She is frequently incontinent of urine and stool and requires assistance with incontinence care. Her care needs are expected to be continuous and unscheduled throughout the day and night. Furthermore, caregiver log support this and demonstrate that she has personal care needs that occur throughout the night. She has been receiving informal support from her daughter who is physically unable to continue to do so. Therefore, it is medically necessary that the patient receive 24-hour split shift personal care, for a total of 168 hours per week. Failure to provide for the patient's personal care needs could result in skin breakdown, infection, or injury.