Appeal type: Medical necessity
Decision: Overturned

Diagnosis: osteoarthritis, dementia.
Treatment personal care services (PCS) of 24 hours per day, 7 days per week (split shift).
The insurer denied coverage for personal care services of 24 hours per day, 7 days per week (split shift).
The denial is overturned.

This is the case of a female patient with advanced dementia that needs substantial assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives with her daughter. The daughter works fulltime and has a young child so, she has limited time to provide care to her mother. The patient has been receiving personal care services (PCS) 70 hours per week; but the daughter is unable to provide the care her mother needs through the evening/night hours and requested PCS 24 hours per day, split shift services, which was denied. External appeal was requested.

In the Uniform Assessment System (UAS), it was noted that she has decreased range of motion and stiffness in joints (specific joints were not noted). Osteoarthritis can affect performance of ADLs and IADLs due to joint pain and limitation of function of upper and lower extremities and the spine. The patient was unable to rate her level of pain due to cognitive impairment. People with advanced dementia are often unable to report pain with usual verbal communication and may express pain through behavior. It is unclear to what extent pain may be a factor in the patient's difficulty with daily tasks. Inactivity and avoidance of movement that aggravates pain may contribute to low level of function for various daily activities. 

The UAS indicates the patient needs maximal assistance for toilet transfer and toilet use; and has frequent urinary and bowel incontinence. She needs a Hoyer lift for transfers to and from bed and wheelchair; it appears this procedure would be necessary to transfer the patient to a commode or toilet. It is not known how often (if at all) transfer to the toilet/commode occurs during the day. The UAS indicates the aide provides incontinence care and skin care. 

The best plan for managing the patient's incontinence is a caregiver who can provide care when needed through the night for toileting/incontinence in order to keep the patient comfortable and help prevent skin damage, urinary tract infection (UTI) and more serious medical complications (e.g., sepsis, renal injury).

The patient has history of falls. The patient is currently non-ambulatory and needs a Hoyer lift for transfers. It appears unlikely that she can get up from bed unassisted; but with dementia the patient may be unaware of her limitations and attempt to get off the bed. Considering the patient's inability to transfer and walk, if she attempted to get off the bed, it is likely she would fall. The chance of this occurring is uncertain, as she may not have the strength to move that much. However, if she moves near the edge of the bed, she needs immediate assistance to either redirect her back to bed or, if she wants to get up, provide assistance for transfer to wheelchair. Falls during the night occur with greater frequency in older people, especially with dementia, when attention to safety is usually diminished. 

Considering the patient's medical history and functional impairment, it is medically necessary, and in the patient's best interest to have caregiver assistance for all ADLs and IADLs, including ADLs that occur at unscheduled or recurring times throughout the day and night. 

Personal Care Services 24 hours per day, 7 days per week, split shift are medically necessary. The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Services of 24 hours per day, 7 days per week (split shift) is reversed. Medical necessity is substantiated.