Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: Personal Care Aide (PCA) Level 2: 12 hours (hrs) per day - 7 days per week; 12 hrs per day-7 days per week a total of 168 hrs per week (split shift)
The insurer denied Personal Care Aide (PCA) Level 2: 12 hours (hrs) per day - 7 days per week; 12 hrs per day-7 days per week a total of 168 hrs per week (split shift).
The determination is upheld.

This is a female patient with a medical history notable for Alzheimer's dementia. The patient is approved for 10 hours per day, 7 days per week for a total of 70 hours per week of personal care assistance. The patient and her care team requested an increase to 24-hour per day split shift care, 7 days per week, for a total of 168 hours per week.
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient's dementia has been worsening and that it is unsafe for her to be left alone for any amount of time; the patient will become confused and begin trying to remove her ostomy bag or begin to hallucinate if not oriented. She is bed bound and unable to reposition herself in bed. She has urinary incontinence and is unable to toilet or change incontinence care supplies without assistance. During hallucinations, she has had episodes of smearing fecal contents after removing her ostomy bag. She is unable to complete any activities of daily living or direct her own care. 
A Uniform Assessment System (UAS) was completed. The patient lives with her son in a one bedroom apartment. Her cognition was severely impaired. The patient was oriented to person only and was not able to recognize her son at times. She has hallucinations and frequently tries to pull out her ostomy bag. For her activities of daily living, the patient requires total dependence for bathing, hygiene, dressing, walking, locomotion, and toilet use. She requires extensive assistance for bed mobility and eating. She is incontinent of urine with no control present. She has a stool ostomy in place. She wears diapers for urinary incontinence care. There was no fall in the previous 90 days. There was no pressure ulcer present. Compared to a previous assessment, the patient showed a decline in functional status. At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 12 hours (hrs) per day - 7 days per week; 12 hrs per day-7 days per week a total of 168 hrs per week (split shift).

The requested health service of Personal Care Aide (PCA) Level 2: 12 hrs per day - 7 days per week; 12 hrs per day-7 days per week a total of 168 hrs per week (split shift) is medically necessary for this patient.
The patient is completely reliant upon others for assistance with activities of daily living. She is unable to direct her own care. She requires assistance with toileting and managing episodes of incontinence care. She is also prone to removing her ostomy bag and requires assistance with cleaning and replacement of the bag. Her care needs are continuous and unscheduled throughout the day and night. Given her provider's description of nighttime behaviors, the expected frequency of her personal care needs would preclude a live-in personal care aide from receiving adequate rest. Therefore, the requested increase to 24-hour split shift care is medically necessary for the patient. Failure to address the patient's personal care needs could result in skin breakdown and or infection.