Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, Alzheimer's Dementia.
Treatment: Increase Personal Care Aide Services to Split Shift for a Total Amount of 168 Hours per Week.
The insurer denied: Increase Personal Care Aide Services to Split Shift for a Total Amount of 168 Hours per Week.
The denial is overturned.

This patient is an elderly female with medical conditions that include arthritis, Alzheimer's dementia, lower extremity thrombosis, anemia, dysphagia, and gastroesophageal reflux disease (GERD). The denial of an increase in personal care aide services to split shifts for a total amount of 168 hours per week is being appealed. The health plan approved live-in services. 
Uniform Assessment System evaluation completed 6 months ago shows severely impaired cognition and functional status is total dependence on all activities of daily living (ADLs). The patient has bowel and bladder incontinence. A letter from the patient's child notes the patient gets confused at night and tries to get out of bed. She is bedbound and needs assistance with activities of daily living. A Hoyer lift is used for transfers. She receives assistance with toileting every two hours and is turned/repositioned every two hours. A letter from the patient's physician notes the patient was diagnosed with COVID last year. Post-COVID, the patient became bedbound, and her dementia progressed. She is incontinent of bowel and bladder. She needs to be turned and repositioned every two hours. A letter from another physician notes the patient's cognitive deficits have resulted in her being bedbound. She requires full care with activities of daily living. Nighttime logs show the patient getting assistance with repositioning and toileting every two to three hours.

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met by the use of informal caregivers, formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services are uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual who 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. This patient has multiple chronic conditions, including dementia. The denial of an increase in personal care aide services to split shifts for a total amount of 168 hours per week is being appealed. The health plan approved live-in services. Uniform Assessment System (UAS) evaluation completed 6 months ago showed severely impaired cognition and the patient requires total dependence on all activities of daily living. She is incontinent of bowel and bladder. The appeal statements support the patient is bedbound and dependent on all activities of daily living. She requires frequent assistance with toileting, transfers, and turning/repositioning. She needs diaper changes and repositioning every two hours due to urinary incontinence as supported in nighttime logs. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed increase in personal care aide services to split shift for a total amount of 168 hours per week is medically necessary.