Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia with behavioral disturbance, insomnia
Treatment: Personal care assistant (PCA) services, 7 days per week, (2)-12 hours split shift
The insurer denied coverage for personal care assistant (PCA) services, 7 days per week, (2)-12 hours split shift.
The denial is upheld.

The patient is a woman with an extensive medical history of chronic conditions including dementia with behavioral disturbance, insomnia, repeated falls, and psychotic disorder with delusions, osteoarthritis, compression fracture and urinary tract infections. She is currently residing at a Nursing and Rehab Center. The patient is noted to require 24/7 care due to cognitive issues and safety. A return to home with split shift services is requested.

The Skilled Nursing Facility (SNF) Physical and Occupational Therapy Progress Summary notes that the patient needs only supervision for ambulation, transfers, bed mobility, dressing, bathing and toileting/toilet transfers. Balance and Endurance are good. No activities of daily living (ADLs) requires assistance. She will need care for cognition and safety problems. This assessment does not indicate Level II tasks that would accompany cuing and supervision. The physical therapy notes that the patient has severe short term memory deficits. Supervision is required for all ADLs. Notes show that the patient needs help with activities of daily living (ADL), but does not specify which. It had been noted by the nurses that she required placement in a geri-chair close to the nurse's station for closer monitoring due to risk for falls secondary to attempting to get out of bed without calling for assistance. A new progress note indicates episodes of confusion. Dementia and the need for safety precautions are noted. No ongoing Level II tasks are noted in this or other progress notes. No specific nighttime needs are noted. She is turned and positioned "as necessary" (PRN) but has been noted to be independent in bed mobility. 

While the appealer notes the patient has multiple chronic conditions requiring needs that include overnight toileting, transfers and bed mobility the submitted documentation does not document nighttime services. The personal care service guideline does not support services for supervision and safety. "...as previously advised, social services districts are NOT required to allot time for safety monitoring as a separate task as part of the total personal care services hours authorized.  However, districts are reminded that a clear and legitimate distinction exists between "safety monitoring" as a non-required independent stand alone function while no Level II personal care services task is being provided, and the appropriate monitoring of the patient while providing assistance with the performance of a Level II personal care services task, such as transferring, toileting, or walking, to assure the task is being safely completed." 

There are problems with her cognitive dysfunction leading to poor safety awareness and thus the need for supervision and cuing, which is clear. The problem is establishing associated Level II tasks that would fit the criteria noted above. However, as previously stated none are documented in the files currently submitted for this appeal.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for personal care assistant (PCA) services, 7 days per week, (2)-12 hours split shift is upheld. Medical Necessity is not substantiated.