Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment:  Personal Care Aide (PCA) Services, split-shift, 24 hours (hrs) per day, 7 days per week
The insurer denied Personal Care Aide (PCA) Services, split-shift, 24 hrs per day, 7 days per week.
The determination is overturned.

The patient is a male with a past medical history of coronary artery disease, congestive heart failure (CHF), hypertension, hyperlipidemia, diabetes mellitus type 2, chronic kidney disease, osteoporosis, carotid artery disease, urinary incontinence, seizure disorder, chronic obstructive pulmonary disease (COPD), dementia, depression, anxiety, gout, history of prostate cancer, insomnia, osteoarthritis, and hearing loss who had been assigned personal care assistant (PCA) services 8 hours per day (8 hours/day), 7 days/week to total 56 hours/week based on assessment The patient was hospitalized due to chest pain and hypertension. The patient was subsequently transferred to rehabilitation.
The physician at rehabilitation noted the patient had a significant decline in medical, cognitive, and functional status following his recent hospitalization and was homebound/bedbound and totally dependent for all of his activities of daily living (ADLs). The provider strongly recommended the patient have PCA services 24 hours, 7 days/week, via 12 and 12 split shifts in order to return safely to the community.  The patient underwent another universal assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, walking, locomotion, transfer toilet, and toilet use while maximum assistance with tasks of managing medication, phone use, bathing, personal hygiene, and dressing upper/lower body. The patient was assessed at extensive assistance with tasks of bed mobility and eating. The insurer sent final adverse determination denial notice continuing to approve PCA services 24 hours/day, 7 days/week, live in and recommended the patient obtain a hospital bed and specialized mattress to help with repositioning in bed. The patient's healthcare advocate provided a letter stating the patient lived by himself and could not call for help, the patient was bedbound and could not reposition himself in bed. 
At issue is the medical necessity of an inpatient stay.
The services are medically necessary. There is documentation from the patient's medical provider of medical necessity of split shift services 24 hours/day, 7 days/week. The patient's medical provider specifically documents the patient requires turning and repositioning every 2 hours. In addition, the patient requires total assistance with toileting and toilet used per universal assessment and therefore has unpredictable and unscheduled care needs that span a continuum of time. The patient's care needs in the overnight hours would not allow a PCA 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies as the insurer suggested. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, 7 days/week, split-shift, are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.