Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift)
The insurer denied Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift).
The determination is overturned.

This is a female patient with a medical history notable for Alzheimer's dementia, age-related osteoporosis, history of falls, and hallucinations. The patient is approved for 7 hours per day, 6 days per week and 4 hours per day, one day per week for a total of 46 hours per week of personal care services. 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 request was denied by the health plan.
The patient's neurologist provided a letter of support for this appeal. The letter states that the patient's Alzheimer's disease is severely impacting her daily living. She requires full assistance with all activities of daily living. She cannot ambulate without assistance. She has a history of falls and osteoporosis. She needs assistance with toileting and with incontinence care. Her care needs arise frequently both during the day and at night; therefore, the physician is recommending split-shift care. Without this, he reports that the patient cannot safely complete any activities of daily living and would be at risk for adverse health outcomes.
Her speech is nonsensical and she is not able to express her needs.
Night time care logs for the patient were provided for review. The logs demonstrate that every 1 to 2 hours she has personal care needs overnight. These tasks include repositioning in bed, toileting, incontinence care, and medication management.
A Uniform Assessment System (UAS) was completed and was available for review. Her cognition was described as moderately impaired. She was alert to person and place. Her procedural memory was not intact. For her instrumental activities of daily living, the patient requires extensive or maximal assistance for all. For her activities of daily living, she requires maximal assistance for bathing. She requires extensive assistance for dressing, walking, locomotion, toilet transfer, and toilet use. She requires limited assistance for hygiene, bed mobility, and eating. She is infrequently incontinent of urine and continent of stool. A task tool associated with the assessment recommended 50.5 hours per week to address her personal care needs. At issue is the medical necessity of Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift).

The requested health service of Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift) is medically necessary for this patient.
The patient's condition as described by her physician appears to be worse than what is reflected in the UAS (Uniform Assessment System). Given that her neurologist has been caring for her and has been performing physical examinations, it stands to reason that her physician has the more accurate assessment of the patient's current functional condition. He states that she is not able to perform any activities of daily living without assistance. Her care needs are expected to be continuous and unscheduled. Nighttime care logs demonstrate that the patient requires personal care assistance every 1 to 2 hours overnight. A live-in personal care aide would not be able to receive adequate rest at night. Therefore, the documentation demonstrates that the requested increase to 24-Hour split shift care is medically necessary and appropriate for the patient.