Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, deep vein thrombosis, and hypertension
Treatment: Personal Care Aide (PCA) Level 1: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week.
The insurer denied the Personal Care Aide (PCA) Level 1: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week.
The denial is overturned.

This elderly female patient has conditions including Alzheimer's disease, deep vein thrombosis, and hypertension. She lives alone. She is appealing denial of an increase in personal care aide (PCA) services, 12 hours per day, seven days per week: 12 hours per day, seven days per week, split shift, for a total of 168 hours per week. The health plan approved 12 hours per day, seven days per week, for a total of 84 hours per week. Uniform Assessment System (UAS) evaluation completed on recently shows severely impaired cognition and functional status: total dependence with housework, meal preparation, managing finances and medications, shopping, bathing, personal hygiene, dressing, locomotion, toileting, and eating; and maximal assistance with bed mobility. Compared to Uniform Assessment System (UAS) evaluation 6 months previously, there has been a decline with cognition and eating. The patient has bowel and bladder incontinence. 
An appeal statement from the patient's doctor notes the patient requires total assistance with transfers and activities of daily living (ADLs). She cannot be left alone. She needs nighttime assistance with toileting and turning/positioning. She does not sleep more than two hours at a time without requiring assistance with toileting, rotating position, or to keep her calm.
An appeal statement from the patient's daughter notes that the patient needs more assistance, and she does not sleep for more than two hours without requiring assistance with toileting, a drink, or bed linens. Nighttime logs are provided showing assistance every 30 minutes to two hours.

The proposed treatment is 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 multiple chronic conditions. She is appealing denial of increase personal care aide (PCA) services, 12 hours per day, seven days per week: 12 hours per day, seven days per week; split shift, for a total of 168 hours per week. The health plan approved 12 hours per day, seven days per week, for a total of 84 hours per week. Uniform Assessment System (UAS) evaluation completed on recently showed the patient requires total assistance with all activities of daily living (ADLs), except maximal assistance with bed mobility. She is incontinent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation 6 months previously, there has been a decline with cognition and eating. The appeal statements and nighttime logs support the patient is dependent with all activities of daily living and requires frequent assistance with toileting, transfers, and turning/repositioning. This patient has continuous needs that cannot be met with the approved 12 hours per day, seven days per week, for a total of 84 hours per week. The proposed personal care aide services, 12 hours per day, seven days per week; 12 hours per day, seven days per week; split shift, for a total of 168 hours per week is medically necessary.