Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, coronary artery disease
Treatment: Customer Directed Personal Assistance Services 7 
Days A Week, Two 12-Hour Shifts per Day (Split Shift)
The insurer denied: Customer Directed Personal Assistance Services 7 Days A Week, Two 12-Hour Shifts per Day (Split 
Shift)
The denial is overturned.

This elderly female patient has medical conditions that include dementia, coronary artery disease, anxiety, and bipolar disorder. She lives alone. The denial of customer directed personal assistance services (CDPAS) to 7 days a week, two 12-hour shifts per day (or a split shift) is being appealed. The health plan approved customer directed personal assistance services to 7 days per week live-in. The plan reports the patient needs less assistance with transferring to toilet, walking, and moving around; she can position herself in the bed with minimal help; and is able to walk longer distances with assistive devices. She does not need to be turned or repositioned in bed every two to three hours. United Assessment System (UAS) evaluation completed 3 months ago shows severely impaired cognition and function status with need for extensive assistance to total dependence with all activities of daily living (ADLs), except limited assistance with bed mobility. She has frequent bowel and bladder incontinence. A statement from the patient's attorneys reports the patient has been receiving split shift care for five years. The patient has progressive dementia. She is now unable to feed herself and is virtually nonverbal. The patient's condition has not improved since the prior United Assessment System evaluation but has deteriorated both cognitively and physically. She needs nighttime help that will allow an aide to get five hours of sleep. The patient has day and night confusion. She needs help with incontinence and toileting. The assessment was based on a "suspect" nurse evaluation where the patient's ability to walk, transfer, etc., was not directly observed. A letter from the Nurse Practitioner, reports the patient has not made any medical 
improvements. She is dependent with all activities of daily living and unable to walk independently. She is unable to feed herself, dress herself, or administer medications. She requires assistance at night because she frequently awakens and needs to be positioned and kept clean.

The requested health service is medically necessary. 

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transferring, turning/positioning, or feeding. 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 who 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 multiple chronic conditions, including progressive dementia. The denial of customer directed personal assistance services (CDPAS) to 7 days a week, two 12-hour shifts per day (or a split shift) is being appealed. The health plan approved customer directed personal assistance services to 7 days per week live-in. Uniform Assessment System (UAS) evaluation completed 3 months ago shows the patient requires extensive assistance to total dependence with all activities of daily living, except limited assistance with bed mobility. She has frequent bowel and bladder incontinence. The appeal statements support the patient has progressive deterioration in physical and cognitive status and needs assistance with all activities of daily living. The statements support the need for continuous care with toileting and positioning. The health plan reports the patient needs less assistance but does not report the patient is able to function without assistance. The information provided by the plan does not support a reduction in customer directed personal assistance services from split shift to live in. The information provided shows that this patient has significant limitations in functioning and needs continuous care during day and night-time with toileting and bed positioning. The approved customer directed personal assistance services live in is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increased customer directed personal assistance services to split shift is indicated.