Diagnosis: Advanced Dementia
Treatment: Increase in Personal Care Services (PCS) to 24 hours/day, 7 days/week (split shift), for a total of 168 hours/week
The insurer denied the increase in PCS to 24 hours/day, 7 days/week (split shift), for a total of 168 hours/week.
The denial is overturned.

This patient has symptoms including advancing dementia, flaccid paraplegia, bed confinement, stage IV (4) sacral ulcer, diabetes, and hypertension. This is an appeal for denial of an increase in personal care services (PCS) to 24 hours/day, 7 days/week, split shift, for a total of 168 hours/week. The plan approved PCS 24 hours/day, 7 days/week, live-in, for a total of 91 hours/week. Uniform Assessment System (UAS) evaluation performed shows moderately impaired cognition, the member is bed bound, and assistance required with all ADLs (activities of daily living).

A letter from the provider notes the member is dependent for all ADLs. She notes the member has need for unscheduled toileting, diaper changes due to incontinence, frequent turning by caregiver, and reminders with eating.

Yes, the proposed treatment is medically necessary.

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

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. The member has several chronic conditions including dementia, paraplegia, bedbound, and stage IV sacral ulcer. She is appealing denial of an increase in PCS to 24 hours/day, 7 days/week, split shift, for a total of 168 hours/week. The plan approved PCS 24 hours/day, 7 days/week, live-in, for a total of 91 hours/week. Per UAS evaluation, the member requires assistance with all ADLs. UAS evaluation performed shows moderately impaired cognition, the member is bed bound, and assistance required with all ADLs. She has incontinence. The appeal letter from her doctor notes that she is dependent with all ADLs. She requires incontinence care and frequent turning. This member has significant physical impairments due to paraplegia. She has a stage IV ulcer and needs frequent turning. The approved PCS live-in is inadequate to meet the member's needs for frequent turning and incontinence care. The proposed increase in PCS (split shift) is medically necessary.