Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Dementia. 
Treatment: Personal care services 24 hours per day (Split-Shift). 

The health plan denied: Personal care services 24 hours per day (Split-Shift). 
The determination is overturned. 

The patient is a male with medical history notable for dementia, coronary artery disease, and congestive heart failure. 
His physician states that the patient has diagnoses of dementia, coronary artery disease, hypertension, congestive heart failure, osteoarthritis, hearing and visual impairment, prostatic hypertrophy with urinary overflowing incontinence, occasional fecal incontinence, and gait/balance impairment. He takes multiple medications which cause increased urinary frequency including at night. Because of the patient's dementia, he is frequently confused, agitated, and up throughout the night. The letter states that the patient cannot have a live-in care aide because he has needs which continue overnight. The patient lives alone and has no informal assistance, and he is getting progressively worse. His dementia has led to increased confusion and disorientation at night. He has now suffered several falls, injuring his knee and elbow. Failure to support him for his needs at night could lead to recurrence of falls with fractures and/or death. 
The patient's health care proxy provided a letter of support for this appeal stating that the patient has multiple ailments and needs assistance with all activities, including transfers, toileting, and dressing. He has frequent nighttime needs due to his congestive heart failure. He has an unsteady gait with a history of falls; he requires assistance with all ambulation. He has incontinence of bowel requiring occasional nighttime cleaning. The patient had been receiving informal support from a relative; however, she was recently diagnosed with cancer and can no longer provide assistance. 
A Uniform Assessment System (UAS) was available for review. The patient lives alone in a studio apartment. The patient's cognition was moderately impaired; he was alert and oriented to person only with forgetfulness. He requires supervision at all times. For his instrumental activities of daily living (IADL), he requires total dependence for meal preparation, housework, and shopping. He requires maximal assistance for finances, medications, stairs, and transportation. For his activities of daily living (ADL), he requires maximal assistance for bathing, hygiene, dressing, toilet transfer, and toilet use. He requires extensive assistance for walking, locomotion, and bed mobility. He requires limited assistance for eating. He is occasionally incontinent of stool and urine. Compared to a prior assessment, the patient showed a decline in cognitive and functional status. 
At issue is the medical necessity of the personal care services 24 hours per day (Split-Shift). 
The health plan's determination of medical necessity is overturned in whole. 
The requested health service is medically necessary for this patient. 
Live-in personal care aides are expected to receive adequate rest each night, including a minimum of 5 hours of uninterrupted rest. If a patient has personal care needs which prevent this rest, then split-shift care is deemed appropriate. 
The physician and healthcare proxy letters document that the patient's needs are continuous throughout the day and night. He has incontinence and requires hands-on assistance for toileting and incontinence care. He is not able to transfer or ambulate without assistance, and his medical problems cause him to require frequent toileting throughout the day and night. His recent falls during the night are evidence of unmet personal care needs. Therefore, the increase to split-shift services is medically necessary and appropriate for the patient. Failure to address his personal care needs could lead to falls, infection, and/or skin breakdown.