Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift)
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift).
The determination is overturned.

This is a female patient with a medical history notable for dementia and incontinence. The patient is approved for 24-hours per day live-in personal care services. The patient and her care team requested an increase to 24 hour split-shift care, and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has a medical history notable for dementia, hypertension, hypothyroidism, glaucoma, venous insufficiency, and arthritis. The patient has issues with gait and balance, numbness of the feet, difficulty with transfers, worsening cognition, confusion, disorientation, and hallucinations. The patient uses a walker but is still a fall risk. The physician requests 24-hour split-shift care to provide assistance with feeding, dressing, bathing, toileting, and transferring. She also requires prompting assistance for completing personal care tasks.
A Uniform Assessment System was completed. The patient lives alone in an apartment. She was alert and oriented to person and place. She requires frequent cueing for all tasks. She is not safe to be left alone and is not able to direct her own care. For her instrumental activities of daily living, the patient requires total dependence or maximal assistance for all. For her activities of daily living, she requires extensive assistance for bathing and dressing lower body. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, toilet use, and bed mobility. She is independent for eating. She is frequently incontinent of urine and occasionally incontinent of stool. There was no fall in the previous 90 days. There was no pressure ulcer present. Compared to a functional assessment from last year, the patient did not show a significant level of functional decline.
Overnight care logs were provided for review. The patient requires assistance every 1-2 hours overnight with changing soiled pull-ups or using the bedside commode. The patient was not able to go more than 3 hours without personal care assistance. At issue is the medical necessity of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift). 

The requested health service of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift) is medically necessary for this patient.
The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, there is a question of whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.
The patient has extensive needs for personal care assistance. She is unable to manage her own toileting and incontinence care without assistance. Her nighttime care logs demonstrate that these needs are occurring continuously throughout the night and preclude adequate rest for a live-in personal care aide. Therefore, approval of split-shift personal care aide is medically necessary for the patient to address her personal care needs.