Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Increase in Personal Care Aide Services from 63 hours per week to 7 days per week, 24 hours a day Split-shift 
The insurer denied: Increase in Personal Care Aide Services from 63 hours per week to 7 days per week, 24 hours a day Split-shift 
The denial is: Upheld

The patient is a female with medical history notable for dementia, gait dysfunction, and incontinence. The patient is approved by the plan for 63 hours per week of personal care aide services. The patient and her care team requested an increase to 7 days per week 24 hours a day split shift  and this request was denied by the health plan. This denial is the subject under review.

Notes from the patient's care plan were provided for review. They state that the patient is incontinent of both bowel and bladder. She is at "high risk for wandering." She is "unable to care for herself." She does not have informal family support and lives alone. Her condition has worsened since her spouse passed away. She is "getting more aggressive" but has not yet seen a geriatric behavioral specialist and has declined medication. She sleeps 6-8 hours per night, "interrupted." The medical group also provided a letter of medical necessity for an increase in Home Health Aid (HHA) services, stating that the patient "needs to receive direct assistance and frequent help with personal care." They also state that she is "alone at night and a high risk for wandering and fall due to impaired cognition."
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was completed over video with the patient and her daughter. The patient lives alone. She was alert and oriented times two with moderately impaired cognition; recall was 0/3 at five minutes. For her Instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, finances, and shopping. She requires maximal assistance for medications, phone use, stairs, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, toilet use, and bed mobility. She requires limited assistance for hygiene and dressing upper body. She is frequently incontinent of urine and continent of stool. She uses pads for incontinence care. Compared to a prior UAS, she showed a functional decline across nearly all domains.

The requested health service of increase in hours in Personal Care Aide Services from the plan approved 63 hours per week to 7 days per week, 24 hours a day Split-shift has not been demonstrated to be medically necessary for this patient.
The patient has dementia, incontinence, and functional limitations which result in requiring assistance with nearly all ADL's and IADL's. However, the provision of split-shift personal care requires that a patient would have continuous personal care needs throughout the day and night. There is no demonstrated necessity for personal care functions to be performed continuously for this patient. She does not require turning and repositioning in bed and would not be expected to require personal care assistance all night long. She does require supervision due to her dementia, but safety monitoring alone (in the absence of providing personal care) is not a level 2 personal care function. The patient has not met the requirements of medical necessity for the requested service of 24-hour split-shift care.