Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, congestive heart failure, and hypertension
Treatment: Increase Personal Care From 24 Hours 7 Days A Week (live-in) To 24 Hours 7 Days A Week (split shift)
The insurer denied the Increase Personal Care From 24 Hours 7 Days A Week (live-in) To 24 Hours 7 Days A Week (split shift)
The denial is overturned

This is a female with conditions including dementia, congestive heart failure, and hypertension. The member wanders.  She is appealing denial of increase personal care (PCA) from 24 hours 7 days a week, live-in, to 24 hours 7 days a week, split shift.  Uniform Assessment System (UAS) evaluation was performed.  She is totally dependent with meal preparation, housework and shopping.  She requires extensive assistance. with stairs and transportation.  She requires maximal assistance with personal hygiene, bathing, dressing, walking, locomotion, and toilet transfer.  She requires limited assistance with bed mobility and eating.  The member ambulates with a walker.  She has frequent bladder incontinence and infrequent bowel incontinence.  She needs assistance with changing pull ups.  She does not have skin breakdown.  

An appeal statement from the member's niece notes that the member has incomplete sleep patterns. She confuses the time of day. She needs nighttime assistance with toileting, meals, and medications. The member burned her leg with hot water.  The member's niece is her caretaker.  

An appeal from NY State notes the member's needs have increased since UAS (Uniform Assessment System) evaluation completed.  The member takes diuretics, which result in her frequently getting up at night to use the bathroom.  She is unable to walk on her own due to unsteady gait.  She cannot clean herself.  The member gets hungry and thirsty during the night.  She requires medications for breakthrough pain during the night.  

A letters from the provider notes that member the member's dementia and functioning are declining. She gets confused and agitated. She gets up frequently to use the bathroom. Notes that the member's sleep patterns are disturbed and she requires nighttime assistance with toileting, medications and meals.  

A Sleep/Wake log is provided and shows the member requiring bathroom assistance every 1-3 hours during the night.

Yes. The Increase Personal Care From 24 Hours 7 Days A Week (live-in) To 24 Hours 7 Days A 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. The member has several chronic conditions including dementia.  She is appealing denial of increase personal care assistance (PCA) from 24 hours, 7 days a week, live-in, to 24 hours, 7 days a week, split shift.  The most recent UAS (Uniform Assessment System) evaluation was performed.  The member requires assistance with all ADLS (activities of daily living).  Appeal statements indicate that the member cognitive and functional status have deteriorated since the UAS (Uniform Assessment System) evaluation performed. She is unable to ambulate without assistance.  She has frequent bladder incontinence.  Sleep/wake logs provided show the member requires frequent assistance with toileting throughout the night.  This member has significant progressive cognitive and physical impairments that require continuous care. The approved 24 hours, 7 days a week, split shift, is inadequate to meet the member's needs for assistance with ADLs/IADLs (activities of daily living/Instrumental activities of daily living).  The proposed increase to 24 hours, 7 days a week, split shift  is medically necessary.

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