Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Personal Care Services 24 Hours split 
shift care,168 Hours Per Week
The insurer denied: Increase Personal Care Services 24 Hours split shift care,168 Hours Per Week
The denial is overturned.

The patient is an elderly female. Her conditions include dementia, hypertension, and osteoporosis. Denial of increase personal care services 24 hours split shift care, 168 hours per week is being appealed. She currently receives live-in care.
The patient's Uniform Assessment System evaluation completed on three months ago shows seriously impaired cognition and functional status: total dependence with housework, managing finances, and shopping; maximal assistance with meal preparation, phone use, transportation, bathing, personal hygiene, toilet use, dressing, and toileting; extensive assistance with walking, locomotion, toilet transfer and eating; and supervision with bed mobility. The patient has frequent bowel and bladder incontinence.
An appeal statement notes the patient has multiple medical conditions and severe cognitive impairment. She lives alone. She requires assistance with ADLs (activities of daily living) and cueing. Her condition has progress to require frequent help using the bathroom and transferring out of the bed during the night. She is incontinent and requires frequent changes. Nighttime logs show the patient receives assistance every two to three hours with toileting. A letter from the patient's daughter notes that the patient needs assistance with ADLs (activities of daily living). The patient has urinary incontinence. Split-shift care is requested, because the patient wakes up through the night and needs assistance with toileting, adjustment in the bed, and changing soiled clothes and linens.

The requested Increase Personal Care Services 24 Hours split shift care,168 Hours Per Week 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 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 personal care services 24 hours split-shift care, 168 hours per week is being appealed. She currently receives live-in care.
This patient has multiple chronic conditions, including dementia. Uniform Assessment System (UAS) evaluation completed three months ago shows the patient requires assistance with all ADLs (activities of daily living), except bed mobility. She is incontinent of bowel and bladder. The appeal statements support the patient is dependent with all ADLs (activities of daily living) and requires frequent assistance with toileting, and transfers. Night-time logs support the patient receives assistance every two to three hours with toileting. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested personal care services 24 hours split-shift care, 168 hours per week, is medically necessary.