Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia.
Treatment: Personal care assistance services, 2 12 hour split shifts, 7 days.

The insurer denied personal care assistance services, 2 12 hour split shifts, 7 days.  The determination is overturned.

This is a female patient with a medical history notable for Alzheimer's dementia, incontinence, diabetes mellitus, and Parkinson's disease. The patient is approved for 12 hours per day, 7 days per week (84 hours per week) of personal care assistance services. The patient and her care team requested an increase to 24-hour split-shift care (2-12 hour shifts), 7 days per week (168 hours per week), and this request was denied by the health plan.

The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient requires assistance with all activities of daily living, including turning and repositioning in bed every 4 hours throughout the night to prevent pressure ulcers.

The patient's daughter provided a letter of support for this appeal. The letter states that the health plan has refused nighttime coverage for her mother and that because of this, the daughter has to go to her apartment each night when the aide leaves. The daughter states she has lost her job over this commitment. She states that overnight the patient awakens 4 times to toilet and change diapers (and bed sheets at times) and that she also helps with monitoring her blood sugars overnight. She reports that she is unable to achieve 5 hours of uninterrupted sleep each night due to her mother's condition.
A Uniform Assessment System (UAS) was completed. The assessment was conducted in person with the patient's daughter present. The patient was minimally oriented with a mini-mental state exam score of 0/30, consistent with advanced dementia. She is not able to make her needs known or be left alone. She requires total dependence for essentially all Instrumental activities of daily living (IADLs). For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, and toilet use. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, and toilet transfer. She requires limited assistance for eating and supervision only for bed mobility. She is frequently incontinent of urine and infrequently incontinent of stool; she uses pullups for incontinence care. At issue is the medical necessity of personal care assistance services, 2 12 hour split shifts, 7 days.

The requested health service of personal care assistance services, 2 12 hour split shifts, 7 days per week is medically necessary for this patient.

The patient requires assistance for all activities of daily living including toileting. The UAS indicates that she is able to perform bed mobility with supervision only, but this assessment was done some time ago. A more recent letter from her provider indicates that she now requires assistance with repositioning in bed. The letter from her daughter also details that the patient has toileting needs frequently throughout the night due to incontinence. Her daughter has been providing informal support overnight but has lost her employment due to this. The patient's care team had demonstrated the medical necessity for split-shift care for the patient. Failure to provide for her personal care needs overnight could result in skin breakdown and/or infection.