Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, depression, and coronary artery disease
Treatment: Increase Personal Care Service Hours, 24 Hours 
per Day, 7 Days per Week (Split Shift), 168 Hours per Week
The insurer denied: Increase Personal Care Service Hours, 24 Hours per Day, 7 Days per Week (Split Shift), 168 Hours per Week
The denial is overturned.

The patient is an elderly female. Her medical conditions include dementia, depression, and coronary artery disease. Denial of an increase in personal care service hours, 24 hours per day, 7 days per week (split shift), 168 hours per week is being appealed. The health plan approved 10 hours a day, 7 days a week. The patient's Uniform Assessment System (UAS) evaluation completed three months ago shows moderately impaired cognition and functional status: total dependence with housework, shopping, and locomotion; maximal assistance with meal preparation, managing medications and finances, bathing, lower body dressing, walking, and toileting; extensive assistance with personal hygiene, upper body dressing, and bed mobility; and limited assistance with eating. The patient has bowel and bladder incontinence. An appeal statement notes the patient has multiple chronic conditions. She lives with her elderly sister who is her primary caregiver. Her sister is no longer able to assist. The patient requires incontinence care every two hours and assistance with activities of daily living. The Uniform Assessment System evaluation completed three months ago compared to 
an assessment completed six months ago shows a decline with the ability to perform the following: manage medications, personal hygiene, lower body dressing, walking, locomotion, toileting, and bed mobility. The patient's provider has stated that the patient cannot take care of her bathroom needs at night and is consistently found soaked in urine in the morning. Nighttime logs show continuous care with toileting.

The requested increase in personal care service hours, 24 hours per day, 7 days per week (split shift), 168 hours per week is medically necessary. 

The denial of an increase in personal care service hours, 24 hours per day, 7 days per week (split shift), 168 hours per week is being appealed. The health plan approved 10 hours a day, 7 days a week.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that 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 several medical conditions, including dementia. Uniform Assessment System (UAS) evaluation completed three months ago shows the patient needs assistance with all activities of daily living (ADLs). She has bowel and bladder incontinence. In comparison to the assessment of six months ago, there has been a decline with the ability to perform the following: manage medications, personal hygiene, lower body dressing, walking, locomotion, toileting, and bed mobility. Appeal statements support the need for assistance with all activities of daily living. The patient no longer has the informal support of her sister. She requires frequent care with toileting due to incontinence as supported by nighttime logs. The information provided supports that this patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved 10 hours a day, 7 days a week, is insufficient to meet the patient's needs. The requested increase in personal care service hours, 24 hours per day, 7 days per week (split shift), 168 hours per week is medically necessary.