Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, osteoarthritis, hypertension, diabetes, and incontinence
Treatment: Increase Home/Personal Care Level 2 To 24 Hours per Day (split shift)
The insurer denied: Increase Home/Personal Care Level 2 To 24 Hours per Day (split shift)
The denial is overturned.

The patient is an elderly male with medical conditions that include dementia, osteoarthritis, hypertension, diabetes, and incontinence. Denial of increase home/personal care to 24 hours per day (split shift) is being appealed. The health plan approved an increase from 56 hours per week to 24 hours per day (live in).
The patient's Uniform Assessment System (UAS) evaluation completed 4 months ago shows moderately impaired condition and functional status: extensive assistance to total dependence with all activities of daily living (ADLs), except limited assistance with eating, and independent with bed mobility. He has frequent bowel and bladder incontinence. There was a functional decline compared to Uniform Assessment System evaluation completed last year. An appeal letter notes the patient needs cuing due to dementia. He needs assistance with activities of daily living (ADLs) throughout the day and night. A letter from the patient's provider notes the patient requires assistance with activities of daily living. He needs assistance with toileting every two to three hours. Activity logs have been provided show the patient receiving nighttime assistance approximately every three hours with toileting, hygiene, and repositioning.

The Increase Home/Personal Care Level 2 To 24 Hours per Day (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 who 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 home/personal care to 24 hours per day (split shift) is being appealed. The health plan approved an increase from 56 hours per week to 24 hours per day (live in). This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed 4 months ago shows the patient needs extensive assistance to total dependence with all activities of daily living (ADLs), except limited assistance with eating, and independent with bed mobility. He has frequent bowel and bladder incontinence. The appeal statements support the patient requires assistance with all activities of daily living ADLs (activities of daily living), including assistance with toileting every two to three hours. Activity logs support that the patient has 
continuous needs with toileting, hygiene, and repositioning. This patient's continuous needs will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested increase home/personal care to 24 hours per day (split shift) is medically necessary.