Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, memory deficit, gait instability, chronic obstructive pulmonary disease (COPD), and coronary artery disease

Treatment: 24 hours per day, 7 days per week Split Shift Personal Care Services level 2

The insurer denied coverage for 24 hours per day, 7 days per week Split Shift Personal Care Services level 2

The denial is overturned

This case involves an elderly female diagnosed with dementia, memory deficit, gait instability, chronic obstructive pulmonary disease (COPD), and coronary artery disease who was being recommended 24 hours per day, 7 days per week (24/7) split shift personal care services level 2. A community health assessment conducted noted that personal care assistance for 10 hours 7 days was being recommended. At the time, the patient had a primary diagnosis of dementia. She lived alone in a one-bedroom apartment on the fifth floor with elevator access. Personal Care Assistance (PCA) services from 9-7 PM (post-meridiem) and during the night with either the daughter or her daughter's friend sleeping over at the patient's home. An updated assessment was conducted with the report noted that the patient is homebound and was only going out for medical doctor appointments. She never stays alone. The daughter reported that the patient is unable to sleep well and was going to the bathroom 6 -8 times a night. She had shortness of breath with moderate exertion due to COPD. The progress notes conducted via telemedicine noted the patient was waking at night up to 6 times to urinate, was disoriented and would take a while to get back to bed. She had a bed alarm and a bedside commode. She had incontinence of urine but rarely stool. She had several falls and had also slid off the bed in the middle of the night. The report stated the patient was able to feed herself but needed assistance for transfers. Exam findings were relatively unremarkable given the telehealth visit. The assessment noted her advanced dementia, gait instability, and falls. The physician stated the patient would benefit from a splint should have 24 -hour caregiver and episodes of falls in the middle of the night along with nocturia that has not responded to lifestyle modifications. The patient required assistance with transfers to the commode in the melanite and was at high risk for injury if not assisted.

The discharge narrative stated that the patient had been admitted due to non-ST (interval on EKG [electrocardiogram]) elevated myocardial infarction. She complained of persistent and worsening dizziness that had failed attempts at outpatient treatment. The home health aide noted the blood pressure was elevated, reports of dizziness, with the patient's baseline mental status documented as alert and oriented to person and place or person, place, and time and was with sundowning confusion at home. She had a 24/7 health aide. The treating physician stated the patient would benefit from having the 24/7 care.

Medical literature notes that personal care services allow individuals to remain in their home environment to receive care instead of receiving treatment within a skilled nursing facility or assisted living. Records noted that the patient was previously authorized personal care services 7 days a week for 10 hours at a time between 9 AM and 7 PM. The report stated the patient had a 24/7 health aide. It was noted that the patient was a fall risk and had urinary incontinence along with dementia, memory deficit, gait instability, COPD, and coronary artery disease. Also noted was that while the daughter or daughter's friends slept with member overnight, daughter reported she is tired of this as she can't wake up every night. There is no obligation of family members to provide care.

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for 24 hours per day, 7 days per week Split Shift Personal Care Services level 2 is overturned. Medical Necessity is substantiated.