Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia. 
Treatment: Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week. 
The insurer denied  Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week. 
The determination is overturned in part. 

The patient is a female with a medical history notable for Alzheimer's dementia. The patient was approved for 12 hours per day, 7 days per week for a total of 84 hours per week of personal care worker services. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient's condition has deteriorated over the last two to three months. She has been falling while walking to the bathroom at night and also while getting out of bed. She has had inappropriate hygiene overnight due to a lack of personal care support. She is no longer able to care for herself independently and requires constant assistance. 
A Uniform Assessment System (UAS) was completed. The patient lives alone in a two-bedroom apartment. She was alert and oriented to person and place during the visit. They noted that she has worsening sundowning and confusion at night. She is occasionally incontinent of urine and infrequently incontinent of stool. Compared to an assessment performed approximately 3 months prior, the patient showed a significant decline in level of function for activities of daily living. At issue is the medical necessity of Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week. 

The services are medically necessary in part. The requested health service of Personal Care Worker (PCW) services 7 days per week, 12 hours per day x 2 split shifts continuous by more than one person; 168 hours per week has not been demonstrated to be medically necessary for this patient. Personal Care Worker (PCW) services 7 days per week, 24 hours per day live-in is medically necessary for this patient. 
The patient requires assistance with essentially all activities of daily living, including toileting, transfers, and ambulation. Because of this, the patient will have personal care needs that are continuous and unscheduled throughout the day and occasionally at night as well. Her recent falls are evidence of unmet personal care needs. Therefore, it is medically necessary that the patient receive 24-hour per day personal care assistance.
There is insufficient documentation that the patient requires 24-hour split shift personal care assistance. Split shift personal care is medically necessary for patients whose personal care needs have been demonstrated to be continuous overnight and of such frequency that a live-in personal care assistant would not be able to receive adequate rest at night. There were no overnight care logs provided for review. The patient is not being treated for a pressure ulcer that requires frequent turning and repositioning. Supervision and safety monitoring alone is not an allowable personal care function, and 24-hour split shift care cannot be authorized merely to provide supervision. However, a live-in personal care aide would be medically appropriate to address any care needs such as toileting which would occur infrequently in the evening and night time.