Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal care assistance 7 days per week, 24 hours per day split shift 
The insurer denied Personal care assistance 7 days per week, 24 hours per day split shift 
The determination is overturned.

The patient has a past medical history significant for dementia with behavioral disturbance, weakness, steady gait, chronic pain syndrome, hypertension, incontinence of feces, anemia, legal blindness, polyneuropathy, osteoarthritis, stress incontinence, glaucoma and vitamin deficiency.
Personal care assistance 7 days per week, 24 hours per day split shift was denied by the health plan and is under review. Services were denied by her insurance stating the following: According to regulations, personal care assistant services for safety supervision alone, such as may be clinically necessary for someone with cognitive dysfunction are not covered services.  Personal care assistant hours for companion care or for safety supervision without the need for activities of daily living tasks, is not required to be covered under your benefit plan.  Safety supervision is included and covered as part of the total authorized personal care service hours when done during activities such as bathing.  It is not covered as a standalone function. There is no data that shows you need someone to help you turn and position you overnight.  Using continence product such as diapers to manage urinary incontinence.  As per regulations, personal care services shall not be authorized if the patient's need for assistance can be met by adaptive or specialized equipment or supplies.
Services were approved for 8 hours per day 7 days a week for total of 56 hours a week. At issue is the medical necessity for personal care assistance 7 days per week, 24 hours per day split shift.
The requested health service personal care assistance 7 days per week, 24 hours per day split shift is medically necessary for this patient.
The Nursing assessment was reviewed. The Uniform Assessment System (UAS) State of New York was reviewed. The tasking tool showed 2138 hours. The Uniform Assessment System (UAS) State of New York was reviewed. The tasking tool noted 28 hours The appeal letter and nighttime log were reviewed.
The patient has multiple medical problems including generalized medical decline along with advancing cognitive changes consistent with dementia and behavioral abnormalities. The patient requires services for all instrumental activities of daily living (IADLs)  and significant assistance for all activities of daily living (ADLs).  The patient's medical status has progressed with advancing dementia between assessments.  The issues at hand which prompted additional services include issues with progressive incontinence, and behavioral issues especially at night.  The behavioral issues include trying to get out of bed and other issues with diapers including soiling her diaper along with taking them off.  Diapers and other continence products are provided for daytime and nighttime to assist with continence needs.  
The main issue is with the nighttime awakening, getting out of bed and other issues.  Unscheduled nighttime issues which include soiling of the diapers and attempting to get out of bed independently create a safety risk. The patient requires significant assistance with all ADLs and IADLs. The provided nighttime log along with the progress notes from the nurse practitioner (NP) support the medical necessity for this care. The patient's daughter is an informal helper but cannot be available consistently for the other times that the aide is not present.