Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legal blindness, dementia
Treatment: Personal Care Aide 24 Hours (split shift) Per Week
The insurer denied: Personal Care Aide 24 Hours (split shift) Per 
Week
The denial is overturned.

This elderly female patient has medical conditions that include legal blindness, hard of hearing, dementia, depression, anxiety, and stage 2 coccygeal pressure injury. The denial of personal care aide 24 hours (split shift) per week is being appealed. The health plan approved live in care. Uniform Assessment System evaluation completed a few months ago shows moderately impaired cognition and functional status shows maximal assistance to total dependence with all activities of daily living, except extensive assistance with eating. The patient has bowel and bladder incontinence. There has been a decline in her functioning when compared last year. A letter notes the patient lives alone and is dependent with all activities of daily living. She sporadically wakes up in the night and needs incontinence care. Her daughter 
is no longer able to provide informal support. The patient requires unscheduled changing, repositioning, feeding, and calming due to depression and anxiety. A letter from the patient's child notes she can no longer provide informal support. The patient is bedbound. The patient requires assistance with activities of daily living as well as cueing. She requires assistance with toileting every 3 hours throughout the night. She wakes up in the nighttime for water and needs assistance reaching for a glass due to blindness. The two nighttime logs do not show a pattern with nighttime needs. Another letter notes the patient is bedbound. The patient is incontinent of bowel and 
bladder and requires frequent diaper changes and repositioning to prevent further skin breakdown.

The proposed treatment is medically necessary. 

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 multiple chronic conditions that include legal blindness, hard of hearing, dementia, and stage 2 coccygeal pressure injury. The denial of personal care aide 24 hours (split shift) per week is being appealed. The health plan approved live in care. Uniform Assessment System (UAS) evaluation completed a few months ago shows the patient needs maximal assistance to total dependence with all activities of daily living, except extensive assistance with eating. She is incontinent of bowel and bladder. The appeal statements support the patient is bedbound and dependent with all activities of daily living. The patient already has a pressure ulcer and requires frequent assistance with toileting, transfers, and turning/repositioning. She needs nighttime assistance with toileting and food/water. She does not have informal support. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed increase personal care aide 24 hours (split shift) per week is medically necessary.