Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, bowel and bladder incontinence, hypertension, CVA with residual left-sided hemiplegia, dysphagia and glaucoma. 
Treatment: Increase Personal Care Services - 24 Hours per Day, Split Shift, Seven Days per Week. 

The insurer denied the Increase Personal Care Services - 24 Hours per Day, Split Shift, Seven Days per Week. 

The denial is overturned. 

This female has medical conditions including Alzheimer's disease, bowel and bladder incontinence, hypertension, cerebral vascular accident (CVA) with residual left-sided hemiplegia, dysphagia and glaucoma.  She is bedbound and ambulates by wheelchair.  She is not oriented and is nonverbal.  She has a percutaneous endoscopic gastrostomy (PEG) for nutrition and medications.  She lives with her spouse.  Her daughter helps with care.  She is appealing denial of personal care services (PCS) 24 hours per day, split shift.  She has been approved for personal care services (PCS) 126 hours per week.  This was a partial approval from personal care services (PCS) 85 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows severe cognitive impairment and functional status: total dependence with meal preparation, housework, managing medications and finances, shopping, transportation, bathing, personal hygiene, dressing, toilet use, bed mobility and eating.  It notes the patient's functional status has declined over the past month.  She is incontinent of bowel and bladder.  She requires nighttime repositioning. An appeal letter notes the patient needs 24 hour, split-shift care due to total dependence with activities of daily living (ADLs) including bed repositioning and other nighttime needs.  She was hospitalized for urinary tract infection (UTI) and developed a sacral wound. 

Yes, the proposed treatment is medically necessary. 

The proposed treatment is consistent with generally accepted standards of medical practice. 

Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the provider five hours daily of uninterrupted sleep during the aide's shift. 

This patient has multiple chronic conditions including Alzheimer's dementia and hemiplegia secondary to cerebral vascular accident (CVA).  She is appealing denial of personal care services (PCS) 24 hours per day, split shift.  She has been approved for personal care services (PCS) 126 hours per week.  The patient is bedbound.  She is not oriented, nonverbal, and requires assistance with all activities of daily living (ADLs) and personal care needs.  She gets nutrition and medications via a percutaneous endoscopic gastrostomy (PEG) tube.  She was hospitalized with a urinary tract infection (UTI) and developed a sacral wound.  Uniform Assessment System (UAS) evaluation completed shows the patient is dependent with all activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  Her functional status has declined over the past month.  She is incontinent, has a sacral wound and requires nighttime repositioning.  Appeal statements indicate that her functional status has declined over the past month and requests 24 hours per day, split shift to assistance with activities of daily living (ADLs) including nighttime needs.  This patient has continuous needs that cannot be met with the approved personal care services (PCS) 126 hours per week.  The proposed increase to personal care services (PCS), 24 hours per day, split shift, is medically necessary to meet this patient's needs for assistance as noted above.