Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Home Health Services

Diagnosis: Dementia, Incontinence
Treatment: Increase in personal care services from 84 hours to 24 Hour(s) per Day (Split Shift)
The insurer denied increase in personal care services from 84 hours to 24 Hour(s) per Day (Split Shift).
The determination is overturned.

This is a female patient with a medical history notable for arthritis, dementia, and incontinence. The patient is approved for 84 hours per week of personal care services. The patient and her care team requested an increase to 24-hour per day split shift personal care services.
The patient's neurosurgeon notes that the patient suffers from dementia, lumbar radiculopathy, spinal stenosis, abnormal gait, neuropathy, incontinence, arthritis, diabetes, hypertensive heart disease, and history of falls. She was hospitalized earlier in the year as a result of urinary tract infection. The patient has difficulty with managing activities of daily living. She is incontinent of bowel and bladder and wears pull-ups throughout the day and overnight. She lives alone and does not have any informal support to help with her condition. 
Overnight care logs were provided for review. They demonstrate the patient's unscheduled personal care needs provided overnight. The patient requires assistance every one to three hours overnight for transfers, toileting, and medication management. There were no 5-hour uninterrupted blocks of time on the overnight care logs.
A uniform assessment system was completed. Her cognition was described as minimally impaired. She is able to call for help in an emergency. For her instrumental activities of daily living, she requires total dependence for meal preparation, housework, and shopping. She requires maximal assistance for transportation and stairs. She requires extensive assistance for finances and medications. For her activities of daily living, the patient requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She is occasionally incontinent of urine and infrequently incontinent of stool. There were two or more falls in the previous three days. Partial loss of skin layers was noted. Compared to a prior assessment, the patient showed a decline in level of function. At issue is the medical necessity of an increase in personal care services from 84 hours to 24 Hour(s) per Day (Split Shift). 

The requested health service of increase in personal care services from 84 hours to 24 Hour(s) per Day (Split Shift) is medically necessary for this patient.
The patient has severe mobility issues as outlined in her physician letters and in the assessment. These issues are complicated by incontinence of urine and feces. They are also complicated by the onset of dementia, which limits her ability to direct her own care and causes her to attempt to do activities that she is not capable of. This has resulted in numerous falls as outlined in the physician letters and the assessments. The patient has had partial loss of skin layers and this could result in further pressure ulcers if not addressed. These elements are evidence of unmet personal care needs and demonstrate that the requested increase in personal care hours is medically necessary for the patient. Additionally, the overnight care logs demonstrate that a live-in personal care aide would not be able to receive sufficient rest at night. Therefore, the request for 24-hour split shift personal care is medically necessary for the patient.