Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease, dystonia, neuropathy, glaucoma and legally blind. 
Treatment: Increase Personal Care (PCA) Services Level 2 to 24 hours per day, 7 days per week, (split shift), for a Total Amount of 168 Hours Per Week. 

The insurer denied the Increase Personal Care (PCA) Services Level 2 to 24 hours per day, 7 days per week, (split shift), for a Total Amount of 168 Hours Per Week. 

The denial is upheld. 

The patient is a female. She has multiple chronic conditions including Parkinson's
disease, dystonia, neuropathy, glaucoma and legally blind. She was recently admitted to subacute rehab after hospitalization for a urinary tract infection. She lives with her daughter. Denial of increase personal care (PCA) services level 2 to 24 hours per day, 7 days per week, split shift, for a total amount of 168 hours per week, is being appealed. The health plan approved an increase from 59.5 to 70 hours per week. 

Uniform Assessment Systems (UAS) evaluation completed shows moderately
impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, and locomotion; maximal assistance with bathing, personal hygiene, dressing, walking, and toileting; and limited assistance with phone use and eating. The patient has frequent bladder incontinence. Comparison of UAS (Uniform Assessment System) from previous to most recent shows deterioration in cognition, upper body dressing, personal hygiene, toileting, walking, locomotion, eating, and bed mobility. 

Appeal letters note the patient needs hands on assistance day and night with transfers and ADLs (activities of daily living). She has a history of falls. She has become more forgetful. There is a log provided that shows the patient wakes up between 4 to 6 AM for toileting. 

No, the requested Increase Personal Care (PCA) Services Level 2 to 24 hours per day, 7 days per week, (split shift), for a Total Amount of 168 Hours Per Week is not medically necessary. 

Yes, the health plan acted reasonably, with sound medical judgment and 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. Denial of increase personal care (PCA) services level 2 to 24 hours per day, 7 days per week, split shift, for a total amount of 168 hours per week, is being 
appealed. The health plan approved an increase from 59.5 to 70 hours per week. 

The patient has several chronic conditions. She was recently admitted to subacute rehab after hospitalization for a urinary tract infection. Uniform Assessment Systems (UAS) evaluation completed previously shows the patient requires assistance with all ADLs (activities of daily living). She has bladder incontinence. Comparison of UAS (uniform assessment system) from the previous to most recent shows deterioration in cognition, upper body dressing, personal hygiene, toileting, walking, locomotion, eating, and bed mobility. Appeal letters note that the patient has a history of falls and needs day and night assistance. The log provided shows the patient wakes up between 4-6 AM for toileting. This patient has significant physical impairments that have progressed between UAS (uniform assessment system) evaluations. The records do not support that 
the patient needs continuous care. She does not frequent turning/repositioning or frequent toileting throughout the night. The requested increase in PCA (personal care assistance) to 24 hours per day, 7 days per week, split shift, for a total amount of 168 hours per week is not medically necessary.