Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: 24 hours per day, 7 days per week (split-shift), total 168 hours per week of Personal Care Services, Level 2
The insurer denied the request for 24 hours per day, 7 days per week (split-shift), total 168 hours per week of Personal Care Services, Level 2.
The health plan's determination is overturned.

The patient is a female with medical history notable for dementia, coronary artery disease, rheumatoid arthritis, history of falls, and urinary incontinence. The patient is approved for 24-hours per day live-in personal care services. The patient and her care team requested an increase to 24 hours per day split-shift, and this request was denied by the health plan. This denial is the subject under review.
The patient's child provided an advocacy letter on behalf of the patient. The letter states that the patient has a stage 1 sacral ulcer which is now worsening to stage 2 and that she is starting to have pressure ulcers elsewhere as well. She is completely bedridden. She cannot maneuver in bed without assistance. She is unable to use the toilet without assistance. The letter notes that the patient's condition has significantly deteriorated since the last Uniform Assessment System (UAS) was performed; she is not able to feed herself or toilet without assistance. There have been multiple instances of falls when attempting personal care tasks without assistance.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has a stage 1 sacral ulcer. She is incontinent of urine and unable to transfer independently. The physician requests split-shift care to allow for turning and repositioning every 2 hours and diaper changes as needed to promote pressure ulcer healing.
A UAS (Uniform Assessment System) was completed and was available for review. The assessment was conducted via teleconference. The patient lives in an apartment with her caregiver. She was alert and oriented to person and place only; she requires frequent cueing and does not have the capacity to ask for help. She requires total dependence of maximal assistance for all Instrumental activities of daily living (IADL's). For her activities of daily living (ADL's), she requires maximal assistance for bathing, dressing lower body, walking, and locomotion. She requires extensive assistance for hygiene, dressing upper body, toilet transfers, and toilet use. She requires limited assistance for bed mobility and eating. She is frequently incontinent of urine and infrequently incontinent of stool. She uses pullups and requires assistance with toileting and changing. Compared with a prior UAS (Uniform Assessment System), she showed a functional and cognitive decline.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of 24 hours per day, 7 days per week (split-shift), total 168 hours per week of Personal Care Services, Level 2 is medically necessary for this patient. The patient is approved for 24 hour live-in care. The increase to split-shift 24 hour care is considered medically necessary if the patient's personal care needs exceed 16 hours per day, or if the needs are of such frequency that the aide would not be able to get a minimum of 5 hours of uninterrupted rest at night. The documentation provided demonstrates that the patient's needs are expected to be continuous and/or unscheduled in nature. She will need turning and repositioning every 2-3 hours throughout the night. She will also require diaper changes for urinary and fecal incontinence. Failure to provide for these needs could result in worsening skin breakdown and/or infection. Therefore, the requested increase to 24 hour split-shift care is medically necessary for this patient.

The health plan's determination of medical necessity is overturned in whole.