Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's Disease.
Treatment:  Increase in Personal Care Services, 24 hours a day, 7 days a week (Split-Shift) for a total of 168 hours.

The insurer denied Increase in Personal Care Services, 24 hours a day, 7 days a week (Split-Shift) for a total of 168 hours.  The health plan's determination is overturned in part.

This is a female patient with a medical history notable for Alzheimer's disease. The patient is approved for 12 hours per day, 7 days per week (84 hours per week) of personal care services. The patient and her care team requested an increase to 24 hours per day (2 12-hour split-shift), 7 days per week (for a total of 168 hours per week), and the request was denied by the health plan.

The patient's physician provided a letter of support for this appeal. The letter states that the patient has multiple chronic medical problems. She requires assistance with all activities of daily living (ADLs). The physician notes that it is "dangerous for her to be left alone at night" due to wandering behaviors. They request increased home care services to "avoid severe complications and frequent hospitalizations."

A Uniform Assessment System (UAS) was completed and was available for review. The patient was oriented to person only with severely impaired cognition. Her daughter directs her care. The patient is unable to be left alone. For her Instrumental activities of daily living (IADLs), the patient requires maximal assistance or total dependence for all. For her activities of daily living (ADLs), she requires total dependence for bathing and dressing lower body. She requires maximal assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for bed mobility and eating. She is incontinent of urine with no control present and is frequently incontinent of stool. 

Nighttime personal care logs were provided for review. The logs demonstrate wandering behaviors and the need for toileting typically between 9:30 PM and 11:30 PM. At issue is the medical necessity of Personal Care Services, 24 hours a day, 7 days a week (Split-Shift) for a total of 168 hours.

In part. The requested health service of increase in Personal Care Services, 24 hours a day, 7 days a week (Split-Shift) for a total of 168 hours has not been demonstrated to be medically necessary for this patient. 24 hour per day live-in personal care (total 91 hours per week) is medically necessary for this patient.

The patient has advanced dementia and severe functional limitations. She is incontinent of urine and stool and unable to manager her own incontinence care. She cannot perform any personal care tasks without hands-on assistance from a caregiver. Her personal care needs are expected to be continuous and unscheduled throughout the day and occasionally at night as well. Therefore, 24-hour care is medically necessary for the patient.

The records do not demonstrate that split-shift care is medically necessary for the patient. Split-shift services are reserved for patients who have personal care needs that occur every 1-3 hours throughout the night and would preclude an adequate rest period for the patient's aide. The nighttime logs show that there is frequently a prolonged period overnight where the patient does not have personal care needs. A split-shift caregiver cannot be approved for safety monitoring only during these periods. Because there is no requirement for turning/repositioning or other personal care need every 2 hours overnight, the request for split-shift 24-hour care has not been demonstrated to be medically necessary for the patient.