Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia
Treatment: Increase in personal care aide services to 7 days a week, 24 hours per day - split shift
The insurer denied an increase in personal care aide services to 7 days a week, 24 hours per day - split shift.
The determination is overturned.

The patient is a male with a medical history notable for Alzheimer's dementia, incontinence, chronic obstructive pulmonary disease (COPD), and coronary artery disease. The patient is approved for 8 hours per day, 7 days per week (56 hours per week) of personal care aide services. The patient and his care team requested an increase to 24 hours per day (split-shift), 7 days a week (168 hours per week).
A letter of support for this appeal was provided by the patient's physician. The letter requests a "modest increase in home health aide help at night" due to his clinical worsening. The letter states he suffered hip and pelvic fractures and is now bed bound and requires turning and repositioning every 2 hours at night to prevent pressure ulcer formation. He states the patient is unable to toilet independently or position in bed. The physician states that he will need constant help throughout the night to address his functional needs.
A Uniform Assessment System (UAS) was completed and was available for review. The review was completed via teleconference. His cognition was found to be moderately impaired; he was not oriented to time but was able to express his needs. From a functional standpoint, he requires total dependence for meal preparation, housework, finances, and shopping. He requires maximal assistance for stairs and extensive assistance for medications. For his activities of daily living (ADLs), he requires extensive assistance for nearly all, including bathing, hygiene, dressing, walking, locomotion, toilet transfer, and toilet use. He requires limited assistance for bed mobility. He is frequently incontinent of urine and infrequently incontinent of stool. He uses pull ups for incontinence care.
Notes from the home health review were provided. The patient lives with his spouse who needs assistance herself. This is a mutual case. The patient is approved for 8 hours per day and the spouse for 4 hours per day, so the total is 12 hours per day. The patient is noted to have frequent bowel and bladder incontinence and cannot care for himself. He wakes up at night and needs assistance.
At issue is the medical necessity for an increase in personal care aide services to 7 days a week, 24 hours per day - split shift.

The requested health service of an increase in personal care aide services to 7 days a week, 24 hours per day - split shift is medically necessary for this patient.
The patient's Uniform Assessment System (UAS) indicates that he requires extensive assistance for nearly all activities of daily living (ADLs) and maximal or total dependence for instrumental activities of daily living (IADLs). He has incontinence and requires assistance with toileting and changing pullups. He cannot be expected to do all of his toileting in an 8-hour window each day. Therefore, it is necessary for him to receive 24-hour care to address his functional needs, especially toileting.  Failure to care for these needs could lead to skin breakdown and/or infection.  His physician attested that he is now bed bound and requires turning and repositioning overnight as well.