Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal care services (PCS), 24 hours/day split shift (two 12-hour shifts), 7 days/week
The insurer denied the PCS, 24 hours/day split shift (two 12-hour shifts), 7 days/week.
The determination is overturned.

This is a female patient with a medical history notable for dementia, asthma, osteoarthritis, and joint pain. The patient was approved for 7 hours/day, 5 days/week and 5 hours/day, 2 days/week (45 hours/week) of personal care services (PCS). The patient and her care team requested an increase to 24 hours/day (2-12 hour split-shift), 7 days/week (168 hours/week) and this request was partially denied by the health plan; they did approve an increase to 8 hours/day, 7 days/week (56 hours/week). The denial of split-shift continuous PCS is the subject under review.

The patient had a recent hospitalization and is now receiving subacute rehabilitation at a skilled nursing facility. Records were provided and were reviewed in detail. She is awaiting the outcome of this appeal as part of safe discharge planning. The records state that she is on hospice care.

A letter of medical necessity for this appeal was provided by the patient's physician. The letter states that the patient has had multiple hospitalizations over the past 6 months due to ataxia and loss of consciousness/syncope. She has advanced dementia and has incontinence of stool and urine. She has had a "rapid cognitive, physical and functional decline" and the physician recommends an increase in home health hours to tend to her functional needs. Due to her toileting needs, she needs continuous care in the day and night.

A letter of support for this appeal was provided by the patient's husband's provider. The letter states that the patient's husband has multiple medical problems including memory issues and is not functionally independent. Because of this, he is not able to assist with the care of his wife.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person at a skilled nursing facility, where the patient is currently residing while awaiting a safe discharge plan. She normally lives with her husband. Cognition was noted to be minimally impaired; she was alert and oriented to person only and unable to direct her own care. For her instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, finances, medications, and shopping. For her activities of daily living (ADLs), she requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, toilet use, and bed mobility. She is frequently incontinent of urine and infrequently incontinent of stool. Skin is intact. A HELPS (Helping Elderly Live Proud and Safe) assessment recommended 55 hours/week to address her personal care needs. At issue is the medical necessity of PCS, 24 hours/day split shift (two 12-hour shifts), 7 days/week.

The requested health service of PCS, 24 hours/day split shift (two 12-hour shifts), 7 days/week is medically necessary for this patient.

The patient has personal care needs that can be expected to be continuous and unpredictable. Because she has advanced dementia and incontinence of stool and urine, she will need assistance with toileting and diaper changes during the day and night. She has had multiple recent falls and hospitalizations which are evidence of her unmet personal care needs (due to attempts to ambulate without assistance). She is not able to receive sufficient informal support from her family and thus the increase to split-shift care is medically necessary. A task tool cannot be relied upon to determine a patient's true level of need when personal care tasks are expected to be frequent and unscheduled.