Diagnosis: Dementia.
Treatment: Personal Care Services, 24 Hours A Day, 7 Days A Week (split shift).

The insurer denied: Personal Care Services, 24 Hours A Day, 7 Days A Week (split shift). The denial is overturned.

The patient is an elderly female with history of dementia. Per the most recent assessment, the patient has history of dementia. The patient is alert and oriented to self, and she is aware that she is at home. She ambulates indoors with the use of a walker. She has a slow and unsteady gait. The patient needs assistance in standing from a seated position and needs help in ambulating. The patient wears diapers for urinary/fecal incontinence. The patient is unable to change incontinence supplies on her own, and she is unable to understand her physical limits. The risks of leaving the patient alone and that she should not be by herself were discussed with the patient's daughter. The patient's condition has declined. The patient needs assistance with activities of daily living with maximal to extensive assistance. The patient is frequently incontinent of bladder, and infrequently incontinent of bowel.

The request is for Personal Care Services, 24 Hours A Day, 7 Days A Week (split shift). The health plan approved Personal Care Services 12 hours a day, 7 days a week, 84 hours total.

The Personal Care Services, 24 Hours A Day, 7 Days A Week (split shift) is medically necessary.

As per the most recent assessment, the patient should not be left by herself. The patient has dementia. She is not able to call 911 for emergencies, and she is not safe to be alone at night.

The patient will require at least supervision for her ADLs (activities of daily living) throughout the day and night. The split-shift hours are needed because the aide would be unlikely to obtain five hours daily of uninterrupted sleep on a regular basis, because the patient's condition has declined. The patient needs assistance with activities of daily living with maximal to extensive assistance. The patient is frequently incontinent of bladder, and infrequently incontinent of bowel.