Diagnosis: Severe Dementia.
Treatment: Consumer Directed Personal Assistance Services - 24 Hours per Day 7 Days per Week (Monday-Sunday) Split Shift for a Total of 168 Hours per Week.

The insurer denied: Consumer Directed Personal Assistance Services - 24 Hours per Day 7 Days per Week (Monday-Sunday) Split Shift for a Total of 168 Hours per Week.

The denial is upheld.

This elderly female patient has dementia. The denial of consumer directed personal assistance services 24 hours per day 7 days per week, split shift, for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week. Uniform Assessment System evaluation completed three months ago shows severely impaired cognition and functional status.
The patient needs total dependence with all activities of daily living (ADLs), except maximal assistance with eating. She is bedbound. She is incontinent of bowel and bladder. A letter from her Provider notes the patient has severe dementia and chronic kidney disease. She is dependent with all activities of daily living, bedbound, and incontinent. She needs prompt changing of diapers during the night to avoid bedsores. She is a fall risk. She cannot stand or transfer on her own. She needs assistance with liquids every few hours.

The proposed treatment is not medically necessary.

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. This patient has dementia. Denial of consumer directed personal assistance services 24 hours per day 7 days per week, split shift, for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week. Uniform Assessment System evaluation completed 3 months ago shows the patient requires assistance with all activities of daily living. She is incontinent of bowel and bladder. An appeal statement supports that the patient needs assistance with all activities of daily living as well as nighttime assistance with changing diapers. The information provide show that this patient has significant limitations in functioning. The information does not support that the patient has continuous needs, such as turning/repositioning every two hours. The information does not support the proposed increase in consumer directed personal assistance services to 24 hours per day 7 days per week, split shift. The proposed increase is not medically necessary.