Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, abnormal gait, pain, muscle weakness, incontinence and insomnia
Treatment: Increase Home Care/Personal Care HHC-Level 2 Personal Care Services From 56 Hours Per Week To 24 Hours Per Day (split shift)
The insurer denied the Increase Home Care/Personal Care HHC-Level 2 Personal Care Services From 56 Hours Per Week To 24 Hours Per Day (split shift)
The denial is overturned.

The patient is a female. Her diagnoses include Alzheimer's dementia, abnormal gait, pain, muscle weakness, incontinence and insomnia.  Denial of increase of Home Care/Personal Care -Level 2 Personal Care Services from 56 hours per week to 24 hours per day, split shift, is being appealed.  She was approved for 56 hours per week.

UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, and housework; maximal assistance with manning finances and medication, bathing, and lower body dressing; extensive assistance with phone use, upper body dressing, walking, locomotion, and toileting; supervision with personal hygiene; supervision with eating; and independent with bed mobility.  She has bowel and bladder incontinence.

An appeal letter from the patient's provider notes that the patient needs assistance with ADLs (activities of daily living).  The letter notes that the patient is a fall risk. The letter recommends 12 hour shift aides.  An appeal statement notes the patient needs assistance with ADLs (activities of daily living), and timing for toileting cannot be predicted.  It further notes that the patient wakes frequently during the nighttime and requires assistance with ambulation, transferring and toileting.  The night logs show the patient needs assistance with toileting at least three times per night.  The personal care logs show overnight toileting approximately every three hours.

Yes, the Increase Home Care/Personal Care HHC-Level 2 Personal Care Services From 56 Hours Per Week To 24 Hours Per Day (split shift)
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. Denial of increase Home Care/Personal Care-Level 2 Personal Care Services from 56 hours per week to 24 hours per day, split shift, is being appealed.  The patient was approved for 56 hours per week.

The patient has several chronic conditions, including dementia.  Per UAS (Uniform Assessment System) evaluation completed, the patient requires assistance with all ADLs (activities of daily living), except bed mobility and eating.  She has bowel and bladder incontinence.  An appeal letter recommends 24 hour split care.  Personal care logs show the patient receiving assistance with toileting approximately every 3 hours during the night.  The need for day and nighttime assistance with toileting cannot be met with the approved personal care service 56 hours per week.  This frequency of assistance is unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.  The proposed increase of personal care service to 24 hours per day, split shift, is medically necessary and appropriate to meets this patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living).

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