Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia.
Treatment: Increase Home Care/Personal Care HHC Level 2 Per 15 minutes to 24 Hours Per Day (split shift).
The insurer denied the Increase Home Care/Personal Care HHC Level 2 Per 15 minutes to 24 Hours Per Day (split shift).
The denial is overturned.

The patient is a male. His medical conditions include Alzheimer's dementia. Denial
of increase Home Care /Personal Care to 24 hours per day, split shift, is being appealed. The health plan approved 35 hours per week.
UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework,
managing finances, and shopping; extensive assistance with making medications, phone use, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and eating; and independent with toilet use and bed mobility. He has infrequent bladder incontinence. Clinical notes from Neurology encounter  are provided. A log of the patient's night time needs is provided. This log shows the patient requiring frequent assistance transfers and toileting throughout the night. There is a current Uniform Assessment System (UAS) evaluation completed. In comparison to the Uniform Assessment System (UAS) evaluation completed previously, there is a need for increased assistance with personal hygiene, dressing, and toilet use. Assistance with toilet use has progressed from independent to need for extensive assistance and bladder incontinence has progressed from infrequent to occasional.

Yes, the requested increase in home care/personal care to 24 hours/day, split shift, is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal
caregivers, by formal services, or by adaptive or specialized equipment or supplies. 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 aide five hours daily of uninterrupted sleep during the aide's shift.

This patient has Alzheimer's dementia. UAS (Uniform Assessment System) evaluation
completed previously shows the patient needs assistance with all ADLs (activities of daily
living), except toilet use and bed mobility. He has infrequent bladder incontinence. Clinical notes from Neurology encounter are provided. A log of the patient's night time needs is provided. This log shows the patient requiring frequent assistance transfers and toileting throughout the night. There is a current Uniform Assessment System (UAS) evaluation completed most recently. In comparison to the Uniform Assessment System (UAS) evaluation completed previously, there is a need for increased assistance with personal hygiene, dressing, and toilet use. Assistance with toilet use has progressed from independent to need for extensive assistance and bladder incontinence has progressed from infrequent to occasional. This information shows that there has been a decline in the patient's physical functioning. The decline has significantly impacted toileting. Night logs show frequent assistance with transfer and toileting throughout the night. This frequency of care would not give the aide five hours daily of uninterrupted sleep during the aide's shift. The currently approved Home Care/Personal Care at 35 hours per week is inadequate to meet this patient's needs for assistance with activities of daily living (ADLs) during the day and night. The proposed increase to personal care assistance (PCA) 24 hours per day, split shift, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.