Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease
Home Health Care/Personal Care Services, 24 hours a day, 7 days a week split shift
The health plan denied the requested Personal Care Services, 24 hrs a day, 7 days a week split shift as not medically necessary. The health plan's determination is overturned.

This is a case review for a male with a medical history notable for Alzheimer's disease and incontinence. The patient is approved for 24 hours per day, 7 days per week (live-in) personal care aide. The patient and his care team requested an increase to 24-hour per day split-shift care, 7 days per week.
Recent office visit notes for the patient were provided for review. He had been in a nursing facility but was removed by the family due to suboptimal care. The patient has been worsening with regards to his advanced dementia. He is suffering from hallucinations. He is contracted in a wheelchair and is bed bound. He is incontinent and overnight has been requiring several diaper changes. This has been challenging for the family, as the patient's daughter has been performing the nighttime personal care tasks, but this places a great strain on her with working a full-time job. Additionally, the patient has a history of a stage 4 pressure ulcer of the right foot. The patient's physician team determined that the patient is completely dependent on assistance with all activities of daily living (ADL) and instrumental activities of daily living (IADL). There is significant caregiver burden with lack of proper resources to care for the patient adequately. They recommend split-shift care for the patient.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via video teleconference. The patient lives with his daughter in their house. His cognition is severely impaired. He is not alert or oriented. He is nonverbal and cannot make his needs known. For his IADL, he requires total dependence for all. For his ADL, he requires total dependence for all. He is bed bound and has severe contractures of the upper and lower extremities. He is fully incontinent and requires total assistance with changing incontinence products for both stool and urine.
At issue is the medical necessity for the requested health service/treatment of Personal Care Services, 24 hours a day, 7 days a week split shift.

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

The requested health service of Personal Care Services, 24 hours a day, 7 days a week split shift is medically necessary for this patient.
The patient has advanced dementia and is unable to perform any activities of daily living for himself. He is completely reliant on others and is not able to make his needs known. He is incontinent of stool and urine. Because he has no control over urine or bowel movements, it is expected that he would require diaper changes throughout the day and the night. The office visit progress notes with the physician corroborate this. Furthermore, the patient has a history of a stage 4 pressure ulcer. He will require assistance with turning and repositioning throughout the day and night. His personal care needs are expected to be continuous and unscheduled throughout a 24-hour period, and therefore split shift personal care is appropriate. Split-shift aides are approved when a live-in aide cannot receive adequate rest in the nighttime due to a patient's personal care needs. He has been receiving informal support from his family, but they are not able to continue to do so, as outlined in the documentation. Therefore, the requested increase to 24 hour split shift care is medically appropriate and reasonable for the patient.