Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Worsening Memory.
Treatment:  Personal care services - 24 hours a day, 7 days week (split-shift) for a total of 168 hours a week.

The insurer denied personal care services - 24 hours a day, 7 days week (split-shift) for a total of 168 hours a week.  The determination is overturned.

The patient has a medical history notable for Alzheimer's dementia, type 2 diabetes, and incontinence of bladder and bowel. The patient is currently approved for 8 hours per day, 5 days per week, and 4 hours per day, 2 days per week (48 hours per week) of personal care services. The patient's care team requested an increase to 24 hours per day (2-12 hour split shift), 7 days per week (168 hours per week), and the insurance company denied this request. At issue is the medical necessity of the personal care services.

A letter of support for this appeal was provided by the patient's physician, who has been treating her since January 2022. The letter states that the patient requires help with transfers, grooming, feeding, toileting, and bathing. The patient needs constant redirecting. The physician feels that the patient requires more home health hours to support her personal care needs to prevent hospitalization or worsening morbidity.

A letter of support for this appeal was also provided by the patient's daughter. The patient lives on her own; the daughter supports the patient when she is able, but she has a family of her own and cannot be there on a consistent basis. There is no other informal family support. The patient has been found twice (once by a physical therapist and once by her health aide) on the floor, unable to get up and soaked in urine. The patient's dementia has advanced, and she cannot do an tasks on her own anymore. The patient is not capable of changing soiled diapers and no longer is aware that she requires changing, so she is frequently found with diapers soaked with urine and overflowing onto the floor.

A recent two-night care log was provided for review. The patient was not able to go more than approximately 3 hours overnight without personal care needs. Even on that short duration, she was found with solid diapers (both urine and stool), requiring not only diaper changes but also bathing and linen changes in the night.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was performed over a video visit. The patient's cognition was noted to be severely impaired; she was only oriented to self and not able to recognize her daughter. She could not direct her own care. For the patient's Instrumental activities of daily living (IADL), she requires total dependence for meal preparation, housework, finances, and shopping. She requires maximal assistance for managing medications and transportation. For the patient's activities of daily living (ADL), she requires maximal assistance for bathing, hygiene, dressing upper/lower body, and toilet use. The patient requires extensive assistance with walking, locomotion, toilet transfer, bed mobility, and eating. The patient is frequently incontinent of stool and urine and uses pull-ups. Compared to a prior Uniform Assessment System (UAS), she showed a large decline in her ability to perform activities of daily living (ADL).