Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Fall-Risk
Treatment: Personal care services (PCS): 24 hours a day, 7 days a week (split-shift) for a total of 168 hours
The insurer denied Personal care services (PCS): 24 hours a day, 7 days a week (split-shift) for a total of 168 hours.
The determination is overturned.

This is a female patient with a medical history notable for dementia, incontinence, and congestive heart failure. The patient is currently approved for 8 hours per day, 7 days per week (56 hours per week) of personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week), and this request was denied by the health plan.

A letter of medical necessity for this appeal was provided by the patient's physician. The letter states that prior to her admission to a skilled nursing facility she was living alone in her apartment and doing well with 8 hours per day of home care services. However, she has had a significant decline in her mental, cognitive, and functional status. She now "requires total assistance for all activities of daily living (ADLs) including, but not limited to, bathing, dressing, housekeeping, food preparation, transferring, as well as total care with all toileting and diaper changing needs." She has severe limitations in her mobility and requires maximum assistance for transferring. She suffers from periods of confusion throughout the day and night due to her dementia. The physician requests turning and repositioning in bed every 2 hours during the day and night. Because of her toileting and bed mobility requirements, the physician states that an attendant will not be "able to get any consecutive hours of uninterrupted sleep."

A letter of support for this appeal was provided by a community advocate. The letter echoed many of the concerns of her physician listed above. The writer expressed concern that the patient would be unable to move, stuck in one position in the same diaper for 16 hours per day when her aide was not present. She is not able to eat, toilet, or transfer without assistance.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented times two; she was forgetful and confused. For her Instrumental activities of daily living (IADLs), she required total dependence for housework. She required maximal assistance for meal preparation, stairs, shopping, and transportation. She required extensive assistance for medications and finances. For her ADLs, she required maximal assistance for bathing and dressing lower body. She required extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She required limited assistance for bed mobility and eating. She was noted to be occasionally incontinent of urine and continent of stool. A task tool associated with the assessment recommended 45 hours per week to address her personal care needs. At issue is the medical necessity of personal care services (PCS): 24 hours a day, 7 days a week (split-shift) for a total of 168 hours.

The requested health service of personal care services (PCS): 24 hours a day, 7 days a week (split-shift) for a total of 168 hours is medically necessary for this patient.
The patient is currently in a skilled nursing facility following a functional decline. The information provided by her physician at the nursing facility is more up to date than the UAS. The physician states that the patient now requires personal care assistance with all functions, and the physician attests that toileting and bed mobility needs will be continuous throughout the day and night. These personal care functions cannot be scheduled into a window during the day as they are expected to be continuous and unscheduled. They will occur throughout the daytime and nighttime, and thus split-shift care is medically necessary.