Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: increase in personal care services to 24 hours per day (split shift).
The insurer denied an increase in personal care services to 24 hours per day (split shift). 
The denial is overturned. 

The patient is a female with a medical history of cognitive impairment secondary to Alzheimer's, hypothyroidism, hypertension, and chronic kidney disease. She has a history of osteoarthritis which causes pain, stiffness, debility, fatigue, deconditioning and gait abnormality. She has a history of wandering from her apartment including late at night.
The patient requires assistance with completion of all activities of daily living. According to the documentation provided she requires total assistance with the following activities of daily living (ADL)s, meal preparation, housework, managing finances, managing medications, phone use, shopping, and using equipment on a frequent and unscheduled basis. She requires extensive maximal assistance with navigating stairs, transportation, bathing, personal hygiene, dressing, walking, locomotion, and toileting including transferring to and from the toilet. She is incontinent of urine and needs to use pull-ups. This requires frequent changing. Further, information provided demonstrates that the patient's condition continues to decline. Specifically, her cognitive function is worsening. In this context, she is unable to retain new information and is not able to be self-correcting. Additionally, it is felt that the use of specialized equipment is inadequate to meet her needs given her frailty, limited mobility, and cognitive decline.
The denial letter from the health plan justifies the determination stating that many of her care needs remained the same. Denial letter states that there are no nighttime needs.
At issue is the medical necessity of Home care/personal care home health care (HHC) - level 2 personal care services to 24 hours per day (split shift).

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Home care/personal care HHC - level 2 personal care services to 24 hours per day (split shift) is medically necessary for this patient.
The patient is a female with multiple medical comorbidities, and in this context most notably a history of Alzheimer's with progressing dementia. According to the information provided, she has significant care needs some of which are not able to be managed during a scheduled daytime regimen. The patient requires total assistance with meal preparation, housework, finances, medications, and use of in-home medical equipment. She requires extensive assistance with bathing, personal hygiene, transportation, locomotion, ambulation, transferring and toileting. It is reported that with her osteoarthritis and cognitive decline she is not able to capably utilize in-home equipment to manage overnight needs such as toileting. Further, she is noted to be incontinent of urine. This will require frequent adult diaper changes. If not addressed promptly the patient will be at significantly increased risk for skin breakdown, pressure ulcers and infection. Further, her cognitive decline has progressed to the point where she has been reported to have nighttime wandering. This degree of dysfunction places her at significant risk. Given the degree of limitations described and the amount of care needs required, this patient qualifies for personal care services 24 hours a day (split shift).
Therefore, the health service/treatment of Home care/personal care HHC - level 2 personal care services to 24 hours per day (split shift) is medically necessary for this patient.