Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, dementia with behavioral disturbance

Treatment: Personal care assistance services from 42 hours per week (6 hours per day times 7 days per week) to two twelve hours SPLIT SHIFT

The insurer denied coverage for personal care assistance services from 42 hours per week (6 hours per day times 7 days per week) to two twelve hours SPLIT SHIFT. The denial was reversed.

This patient is a female with diagnoses: dementia with behavioral disturbances/ hallucinations, arthritis, hypertension, diabetes mellitus, coronary artery disease with angina, coronary stent restenosis, hypercholesterolemia, paroxysmal atrial fibrillation, hypothyroidism, bilateral carotid artery stenosis, gastroesophageal reflux disease (GERD), lumbar paraspinal muscle spasms. The patient is on many medications which have negative side effects and need monitoring. There was an incident when patient fell and could not get up; police and first responders were called. Due to dementia, patient is unable to make consistent, coherent decisions. Outbursts of screaming are increasing and unpredictable. She needs assistance with most activities of daily living (including toileting and mobility/walking) and housekeeping tasks. Patient has lost weight and this is connected to her deteriorating memory. She needs monitoring to ensure she consumes her meals. She recently had two procedures on her left eye for cataract. She has visual impairment of both eyes, severely in the left eye. The patient cannot live independently and needs 24/7 care.

The patient has several medical conditions that most likely contribute to her functional impairment. The patient has dementia, which has a substantial effect on her mental and physical functioning. Dementia results in gradual, progressive loss of ability to perform IADLs and ADLs and exacerbates the functional loss caused by other medical conditions. The records indicate that the patient's cognitive status has declined significantly in the past year. Based on the UAS and information provided by the physicians, it is apparent the patient is dependent on caregiver support for all daily activities. Some activities can be scheduled within a limited time frame each day (e.g. housekeeping, bathing, and personal hygiene). However, the patient also needs assistance for ADLs that occur throughout the day, i.e. transfers, walking, toileting. These activities can occur at any time of the day or night. For a person with dementia, the need to get up and move to another location in the house can be unpredictable. 

NYS regulations for 24 hour live-in aide require that patient's care needs are of such frequency that the aide can expect to have at least 5 uninterrupted hours of sleep each day. If the patient's care needs do not allow for this amount of sleep for an aide, then split shift is necessary. The UAS reports the patient has difficulty falling asleep or staying asleep (noted as daily in previous 3 days). The physician describes unpredictable behavior (e.g. screaming outbursts, hallucinations). It is not known whether Haldol is still prescribed, or is effective. However, its use supports the concern that the patient is at risk for getting out of bed at night, and therefore, in need of assistance during the night. Therefore, it is in the patient's best interest to provide 24 hour PCA services, two 12 hours split shift to ensure the patient has the necessary assistance for walking, transfers and toileting throughout the day and night.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for an increase in personal care assistance services from 42 hours per week (6 hours per day times 7 days per week) to two twelve hours SPLIT SHIFT is substantiated. The insurer's denial is reversed.