Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Parkinson's Disease.
Treatment: Home Health Care/increase in Home Care I Personal care services from 24 Hour(s) per Day (Live In) to 24 Hour(s) per Day (Split Shift).
The health plan denied the requested increase in Home Care I Personal care services from 24 Hour(s) per Day (Live In) to 24 Hour(s) per Day (Split Shift).
The decision is overturned.

This is a case review for a female with a medical history notable for Parkinson's disease, dementia, and incontinence. The patient is approved for 24-hour live-in personal care services. The patient and her care team requested an increase to 24-hour split-shift services.
A letter of support for this appeal was provided by the patient's physician. The letter notes that the patient has had a significant progression of her Parkinson's and dementia which has resulted in physical and cognitive decline. She is reliant on others for all instrumental activities of daily living (IADLs) and activities of daily living (ADLs) but she cannot remember this, which has led to numerous falls and emergency department visits.
An after-visit summary from an emergency department visit was provided for review. The patient was seen for altered mental status. She was treated with antibiotics. She was diagnosed with acute kidney injury, troponin elevation, and unspecified cerebrovascular accident.
A Uniform Assessment System (UAS) was completed and was available for review. Cognition was severely impaired; the patient was not self-directing and was non-verbal. From a functional standpoint, she requires total dependence for meal preparation, housework, finances, medications, phone use, shopping, and transportation. For her ADL's, she requires total dependence for toilet use, dressing upper body, and lower body. She requires maximal assistance for bathing, hygiene, walking, locomotion, toilet transfer, and bed mobility. She requires extensive assistance for eating. She is frequently incontinent of both bladder and bowel. Compared with a prior assessment she showed worsening of her functional status.
At issue is the medical necessity for the increase in Home Care I Personal care services from 24 Hour(s) per Day (Live In) to 24 Hour(s) per Day (Split Shift).

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

The requested health service of increase in Home Care I Personal care services from 24 Hour(s) per Day (Live In) to 24 Hour(s) per Day (Split Shift) is medically necessary for this patient.
The patient has advanced dementia and is unable to speak or direct her own care. She requires maximal assistance or total dependence for nearly all ADL's and IADL's, including toileting. She is incontinent of stool and urine. It is medically necessary for her to receive continuous 24 hour care (split-shift) to address her functional needs. She requires prompt attention to toileting needs during the day and night due to her incontinence. A live-in personal aide would require at least 5 hours of uninterrupted rest, but the patient cannot go that long without incontinence care. Failure to address these needs could result in infection and/or skin breakdown.