Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transient Ischemic Attack with Left-Sided Weakness, Dementia

Treatment: Increase personal care services to 24 hours a day, 7 days a week (split shift)

The insurer denied coverage for Increase personal care services to 24 hours a day, 7 days a week (split shift)

The denial is overturned

The patient is seeking coverage to increase personal care services to 24 hours a day, 7 days a week (split shift).  The patient had age-related physical debility, history of transient ischemic attack with left-sided weakness, memory deficit, dementia with behavioral disturbance, urge incontinence of urine, renal insufficiency, kidney failure, atrial fibrillation, and bilateral glaucoma.

Computed tomography (CT) of the patient's head noted periventricular and subcortical white matter density changes that were consistent with the sequela related to microvascular ischemia or demyelination.

The provider stated that the patient was homebound/bedbound and needed home care throughout the day and night.  The patient required extensive or maximal assistance with activities of daily living including toileting, transferring, turning and positioning, ambulating, meal preparation, bathing, dressing, and grooming.  The patient needed an aide to assist with ambulation, toileting, and transfer/repositioning and unscheduled times throughout the day and night.  The patient lived with a spouse who was not physically capable of providing the patient with assistance to meet their personal care needs on a daily and regular basis.  Care plan notes reported that the patient's condition continued to deteriorate with little to no improvement.  Since the patient had a stroke, the patient had become more dependent and frequently had urinary tract infections.  Antibiotics were not helping. The patient had become incontinent of urine and more dependent for activities of daily living.

Patients who require uninterrupted care by more than 1 personal care aide for more than 16 hours in a calendar day may be appropriate for 24-hour split shift services when a personal care aide is unable to obtain 5 hours daily of uninterrupted sleep during the 8-hour sleep schedule.  In this case, the patient was receiving 9 hours of personal assistance services a day for a total of 63 hours/week.  There was a request to increase the number of hours to 24 hours a day, 7 days a week (split shift).  The appeal information indicated that the patient had frequent falls, cognitive decline, and had functional decline.  There was increased difficulty in taking care of the patient once the home care aides left.  The patient had frequent urinary tract infections.  The treating provider noted that the patient required extensive or maximal assistance with activities of daily living including toileting, transferring, turning and positioning, ambulating, meal preparation, bathing, dressing, and grooming.  The patient needed an aide to assist with ambulation, toileting, and transfer/repositioning and unscheduled times throughout the day and night.  Based on the documentation, the denial of increased personal care services was not supported.  The patient no longer had a normal sleeping schedule and was up frequently throughout the night. Given the patient's increased nighttime needs, decreased functional capabilities, and increased cognitive deficits, a home health aide would not be able to obtain 5 hours of uninterrupted sleep during an 8-hour sleep schedule.  Thus, the denial of coverage for increase personal care services to 24 hours a day, 7 days a week (split shift) 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 increase personal care services to 24 hours a day, 7 days a week (split shift) is substantiated.