Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia and stroke. 
Treatment: Personal care services 24 hours a day, 7 days a week (split shift). 

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

The denial is overturned. 

This case involves an adult patient regarding the denial of coverage for personal care services 24 hours a day, 7 days/week (split shift).  The assessment noted the patient lives with a spouse/partner in a private dwelling and had a list of multiple diagnoses/medical conditions for which she was receiving care.  In terms of cognition, the patient was severely impaired with memory problems affecting short-term memory, procedural memory, and situational memory.  She had impairments with making herself understood and her ability to understand others and reported major life stressors in the last 90 days.  She was totally dependent for bathing, personal hygiene, dressing the upper and lower body, and with locomotion.  She needed extensive assistance with walking, and primarily used a wheelchair or scooter.  She needed extensive assistance with toileting transfers and was totally dependent for toilet use and bed mobility.  She needed limited assistance with eating with no changes noted in her ability to perform activities of daily living as compared to 90 days prior.  Additional findings noted that she was totally dependent for meal preparation, ordinary housework, managing finances, phone use, stair navigation, shopping, and transportation.  She was frequently incontinent for both bowel and bladder and used pads or briefs.  She had adequate hearing and vision and was severely impaired cognitively.  She had a history of frequent falls and hospital admissions.  The patient had no falls in the last 30 days but had fallen between 31 and 90 days prior.  The report stated the patient was diagnosed with Lewy body dementia, anxiety, and depression.  She had a history of cerebral infarction x2 managed with Plavix.  The report also noted the patient had a fall in the bathroom that resulted in a left hip fracture.  The patient required partial hip replacement at that time.  According to the patient's spouse, she has Lewy body dementia, Parkinson's, and residual effects from the cerebrovascular accidents that have impacted her ability to manage activities of daily living (ADL) and instrumental activities of daily living (IADL). 

Personal care services (PCS) allow patients to remain in the comfort of their own home to receive care/treatment rather than residing in a skilled nursing facility, long-term acute care, or assisted living.  The records provided for the review documented that the patient has multiple medical conditions to include severe dementia, which places her at an increased risk for injury given that her cognitive decline prevents her from self-awareness and can lead to falls or other activity related injuries.  The records confirmed that the patient was almost totally dependent for nearly all activities of daily living and instrumental activities of daily living.  The patient had bowel and bladder incontinence that required frequent changes in clothing and adult undergarments.  The patient was taking multiple medications and had a history of falls, which resulted in a hip fracture that required surgery.  In taking the totality of the patient's medical history and consideration in her current functional status, for her safety and wellbeing, the 24-hour care, 7 days a week (split shift) is medically necessary.  The prior determination is overturned. 

Based on the above, the insurer's denial must be overturned. 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 personal care services 24 hours a day, 7 days a week (split shift) is substantiated.