Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia; Glaucoma. 
Treatment: Increase Personal Care Services to 24 Hours A Day, 7 days A Week (Split Shift) for a Total of 168 Hours per Week, Pre-service. 

The insurer denied the Increase Personal Care Services to 24 Hours A Day, 7 days A Week (Split Shift) for a Total of 168 Hours per Week, Pre-service. 
The denial is overturned. 

The patient is a female. Denial of increase personal care services (PCS) to 24 hours a day, 7 days a week, split shift for a total of 168 hours per week, is being appealed. The plan approved 54 hours per week. 

Assessment completed shows the patient needs help with meal preparation, housekeeping, laundry, shopping, dressing, bathing, toileting, and personal hygiene. She is unsteady and uses a wheelchair for locomotion. She is forgetful at times. She lives with her daughter, who assists with managing medications and finances. 

A statement from the patient's designee notes the patient has progressive dementia and is legally blind due to glaucoma. She has functional and physical decline. She needs help with ADLs (activities of daily living). Care twenty four hours per day, split shift is recommended.

A statement from the patient's ophthalmologist states the patient is legally blind due to glaucoma and has progressive dementia. The maximum home attendant hours is recommended. 

Nighttime logs show the patient going to the bathroom every two hours. 

Yes, the requested increase in personal care services to 168 hours/week, split shift, is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase personal care services (PCS) to 24 hours a day, 7 days a week, split shift for a total of 168 hours per week, is being appealed. The plan approved 54 hours per week. The Plan denied the proposed treatment as being not medically necessary. The plan stated care can be provided by splitting current services into 2 shifts, no medical need to get up at night, and time is not provided for companionship or safety supervision. 

The patient has progressive dementia and is legally blind. The assessment showed the patient needs help with help with meal preparation, housekeeping, laundry, shopping, dressing, bathing, toileting, and personal hygiene. Appeal statements note the patient has functionally declined. Nighttime logs show the patient going to the bathroom every 2 hours. This patient has significant physical impairments, and she requires a wheelchair for locomotion. The information provided shows that she has frequent nighttime needs for toileting every 2 hours. This patient's limitations and frequency of assistance needed cannot be adequately met with the approved PCS (personal care services) 54 hours per week. The frequency of care needed would not allow an aid five hours daily of uninterrupted sleep during the aide's shift. The requested increase personal care services (PCS) to 24 hours a day, 7 days a week, split shift for a total of 168 hours per week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The requested increase in personal care services hours to 168 hours/week, split shift, is medically necessary.