Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia.
Treatment: Home Care / Personal Care HHC - Personal Care Aide - Live-In per diem Increase to 24 Hour(s) per Day (Split Shift). 
The insurer denied Home Care / Personal Care HHC - Personal Care Aide - Live-In per diem Increase to 24 Hour(s) per Day (Split Shift). 
The health plan's determination is overturned. 

This patient is a female with medical history notable for dementia, incontinence, and heart disease. The patient is approved for 24-hour live-in personal care, 7 days per week (91 hours per week). The patient and her care team requested an increase to 24 hour per day split-shift (2-12-hour shifts), 7 days a week (168 hours per week). Per the patient's physician, the patient has severe Alzheimer's dementia, urinary incontinence, a stage 1 sacral decubitus ulcer, coronary artery disease, chronic obstructive pulmonary disease (COPD), obesity, and degenerative disc disease. The patient has had a decline in her status over the past few months. She has advanced dementia and is bedbound. The physician states that frequent position changes are needed for her decubitus ulcer. She has incontinence 4 times per day and requires toileting 3-4 times overnight. She has had recent falls. She needs full assistance with toileting, transfers, and bed mobility.
A Uniform Assessment System (UAS) was completed. The assessment was conducted via teleconference. The patient was alert but confused and disoriented. She is not self-directing and unable to ask for help. She requires maximal assistance or total dependence for all Instrumental activities of daily living (IADL)'s. For her activities of daily living (ADL)'s, she requires total dependence for bathing, hygiene, dressing, locomotion, toilet transfer, and toilet use. She requires maximal assistance for bed mobility and eating. She is completely incontinent of bowel and bladder. She uses 8-10 pull-ups per day to manage incontinence care. 
At issue is the medical necessity of Home Care / Personal Care Home Health Care (HHC) - Personal Care Aide - Live-In per diem Increase to 24 Hour(s) per Day (Split Shift).

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

The requested health service of Home Care / Personal Care HHC - Personal Care Aide - Live-In per diem Increase to 24 Hour(s) per Day (Split Shift) is medically necessary for this patient.
The patient currently receives 24-hour live-in care, and the request is for split-shift care. The live-in personal aide must be given adequate rest for each 24-hour period, including the expectation of a minimum of 5 hours of uninterrupted rest each night. If the patient's personal care needs preclude this required rest period, then split-shift care is medically necessary. The patient's needs are extensive; she requires assistance for all activities of daily living including toileting and transfers. She is dually incontinent with no control present and requires a change of her diapers every 2-3 hours. She has a pressure ulcer and requires frequent turning/repositioning in bed to promote healing and prevent recurrence. Her care needs are expected to be continuous and unscheduled throughout the day and night. The records from her physician and family corroborate this. Therefore, the requested increase to split-shift care is medically necessary and appropriate for the patient.