Diagnosis: Dementia.
Treatment: Personal care assistance 24 hours a day, 7 days per week (Split Shift).

The insurer is denied coverage for personal care assistance 24 hours a day, 7 days per week (Split Shift). The denial is overturned.

This is a female patient, who has physical and cognitive impairment, which results in significant decline in her ability to perform most daily activities. Many daily tasks can be managed within the current 12 hours of personal care assistance (PCA) services per day. However, the patient needs assistance with transfers, walking and toileting, which occur at various, unscheduled times throughout the day and night. Therefore, it is medically necessary for the patient to have caregiver assistance for these activities of daily living (ADLs) throughout the day and night. It is reported that the patient usually gets up to use the toilet on average of 3 times per night. The specific times probably vary, and the frequency may not allow a live-in aide to have at least 5 uninterrupted hours of sleep per night, as required by New York State regulations for live-in aides. In addition, due to dementia and nighttime confusion, the patient may have other unpredictable reasons for wanting to get up at night, and assistance is needed for transfers and walking each time she wants to get out of bed. Therefore, it is medically necessary and in the best interest of the patient to have PCA 24-hour continuous services (split shift) to ensure a caregiver is present throughout the night to provide assistance with mobility/ADLs when needed.

It was noted in a letter from the patient's relative and the UAS that the patient does not have local informal caregivers who can provide assistance on a regular basis. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. When informal caregivers are not available to provide care on a consistent basis, then personal care services are indicated to provide the necessary assistance with daily activities, including ADLs that occur throughout the day and night.

Due to medical conditions causing physical and cognitive impairment, the patient needs assistance to ensure proper and safe performance of all daily activities and to decrease the occurrence of adverse health and safety events.

Personal Care Assistance services 24 hours per day, 7 days per week, split shift is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for Personal Care Assistance 24 hours a day, 7 days per week (Split Shift) is overturned. The medical necessity is substantiated.