Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Personal Care Services 24 hours a day, 7 days a week (split shift), 168 hours total

The insurer denied coverage for Personal Care Services 24 hours a day, 7 days a week (split shift), 168 hours total

The denial is overturned

This case pertains to an elderly patient who lives alone. The patient is diagnosed with coronary artery disease (CAD), congestive heart failure (CHF), hypertension (HTN), osteoarthritis (OA), advanced degenerative joint disease in the bilateral knees, chronic pain syndrome, vitamin D deficiency, insomnia, major depressive disorder, urinary incontinence, activity intolerance, ataxic gait, history of falls, and dementia. The patient's medications include ammonium lactate cream, bisacodyl, clotrimazole cream, diclofenac, docusate, Eliquis, escitalopram, Exelon patch, furosemide, hydrocodone-acetaminophen, losartan, MiraLAX, multivitamin, nystatin powder, omeprazole, pantoprazole, spironolactone, tramadol, Tylenol, vitamin B12, vitamin D, and Voltaren gel.

The provider noted the patient needs to be turned every two hours to prevent pressure ulcers. The provider's recommendation was for 2-12 hour shifts, 7 days per week, of personal care services. The patient suffers from age-related physical disabilities and cognitive decline with severe mental deterioration and memory loss due to progressive dementia. The patient is unable to ambulate and is wheelchair dependent. The patient must be placed in the wheelchair and wheeled. The patient cannot do it themselves, and cannot hold their posture in the wheelchair. 

A letter was sent from the insurer reducing the patient's personal care services hours to 24 hours a day, 7 days a week, live-in with 91 hours of personal care. 

The patient is severely impaired cognitively. The patient is unable to state their name or date of birth. The patient is not capable of activating a personal emergency response system (PERS). The assessment reported that the patient was bed-bound. The patient was recently hospitalized due to COVID-19. The patient has been bed-bound since then. The patient is unable to get to the toilet and is toileted in their bed. The patient is frequently incontinent of bladder and bowel with some control. The patient's incontinent garments are checked every two hours. The patient is totally dependent for meal preparation, housework, shopping, bathing, dressing, toileting, eating, and bed mobility. The patient requires maximum assistance with personal hygiene. 

According to the assessment, this patient had a recent decline in their function after a hospitalization with COVID-19. The patient is now bed-bound and requires turning every 2 hours to prevent pressure ulcers. The patient is severely impaired cognitively and cannot be left alone. One caregiver would be unable to achieve 5 hours of uninterrupted sleep. The request for two 12 hour shifts 7 days a week is appropriate in this case. The decision is overturned. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Services 24 hours a day, 7 days a week (split shift), 168 hours total is substantiated.