Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease
Treatment: Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hours per Day (Split Shift) 
The insurer denied Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hours per Day (Split Shift). 
The determination is upheld.

This is a female patient with a medical history notable for Alzheimer's dementia, mobility issues, chronic pain, and seizure disorder. The patient was receiving 56 hours per week of personal care services. The patient and her care team requested an increase to 24-Hour per day split shift care, and this request was partially denied by the health plan. They did approve 24-hour per day live-in personal care. The denial of split shift care is the subject under review.
Recent hospitalization notes were provided for review. The patient was admitted with urosepsis requiring pressor support and acute hypoxic respiratory failure secondary to flash pulmonary edema. She was admitted to the intensive care unit. The patient received appropriate treatment of her infection and for heart failure. She was subsequently discharged. Acute rehabilitation was recommended, but the patient's family declined and she was discharged home with home services.
A Uniform Assessment System (UAS) was completed. The patient lives with her husband in a private house. The patient's cognition was severely impaired. She is unable to make her needs known or direct her own care. For her instrumental activities of daily living, she requires maximal assistance or total dependence for all. For her activities of daily living, she requires maximal assistance for bathing, hygiene, dressing, and toilet use. She requires extensive assistance for walking, locomotion, toilet transfer, bed mobility, and eating. She is incontinent of both urine and stool with no control present. She requires diaper changes four to six times per day. She had at least two falls in the previous 30 days. There was no pressure ulcer present. Compared to a prior assessment, the patient showed a cognitive and functional decline.

The requested health service of Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hours per Day (Split Shift) has not been demonstrated to be medically necessary for this patient.
The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, the question is whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.
There is insufficient evidence that the patient has personal care needs which would preclude adequate rest for her personal care aide. There are no nighttime logs documenting her needs. She requires 4 to 6 diaper changes per day. She does not have any pressure ulcer present at this time which would require turning and repositioning overnight. Therefore, the requested increase to split shift personal care has not been clearly demonstrated to be medically necessary for this patient.