Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, incontinence, coronary artery disease, arthritis, and osteoporosis
Treatment: Personal Care Services- 24 hours a day, 7 days a week (split-shift)
The health plan denied the requested health service/treatment of Personal Care Services- 24 hours a day, 7 days a week (split-shift).
The health plan's determination is overturned.

The patient is a female with a medical history of dementia, incontinence, coronary artery disease, arthritis, and osteoporosis. She is currently receiving 70 hours per week of personal care services and requested an increase to 24 hours daily (split-shift).
The patient's daughter testifies that the patient lives alone. The aide, who is currently paid through the health plan for 70 hours per week, leaves when the patient is asleep but comes back later to provide additional overnight care. This care is under a self-pay model from the patient, and she is no longer able to afford this.
The patient's treating physician states that she is homebound, and her care is complicated by dementia and gait disturbance. They specifically request help with bathing, dressing, transferring, toilet and continence care, meal preparation, and feeding.
A Palliative Performance Scale Score (PPSv2) was 30%, indicating that she is totally bed bound, unable to do any activity due to extensive disease; she requires total care (unable to provide self-care); consciousness is listed as full to drowsy with or without confusion.
A telehealth assessment of the patient's functional status states that there is not sufficient space for a live-in aide. She is unable to get up from a seated position or complete toileting without human assistance. Bowel and bladder incontinence is noted.
A log provided by the patient's overnight caregiver shows a pattern of having toileting needs every 2-4 hours. She had an episode of incontinence one night that necessitated cleaning the patient and her bedding. She was also noted to have bowel movements overnight.
A Uniform Assessment System (UAS) was found the patient alert and oriented to person only. Her 5-minute recall is 0/3. She is unable to call 911 or make her basic needs known. She requires total dependence for meal preparation, housework, finances, and phone use. She requires maximal assistance for managing medications. For her activities of daily living (ADL), she requires total dependence for locomotion, toilet transfer, and toilet use. She requires maximal assistance for bathing, hygiene, and dressing upper/lower body. She requires extensive assistance for bed mobility and eating. She is frequently incontinent of urine and infrequently incontinent of stool; she wears pull ups and is unable to change them by herself.
At issue is the medical necessity of 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 personal care services- 24 hours a day, 7 days a week (split-shift) is medically necessary.
The patient has advanced dementia, frequent urinary incontinence, and functional limitations. She is bed bound and reliant on others for Instrumental activities of daily living (IADL) and ADLs. She has frequent requests for toileting and has episodes of incontinence. She has been able to stay in her own home due to covering her personal care needs out of pocket, but she is no longer able to do so. Without personal care coverage 24 hours per day, she will remain in bed in soiled pull ups and bedding. This could rapidly lead to skin breakdown or infection. These needs for personal care services occur 24 hours per day and on an unpredictable schedule, so delegating her hours using an hourly tasking tool is not an appropriate method of determining her true functional need. The assistance is not for the sole purpose of safety and security; the overnight logs demonstrate a need for ongoing personal care services throughout the night.