Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, arthritis, hypertension, gastroesophageal reflux disease (GERD), depression, weakness, chronic pain, diabetes, and anemia
Treatment: Increase in Personal Care Services (PCS) to 24 Hours/Day, 7 Days/Week (Split-Shift), for a Total of 168 Hours/Week
The insurer denied an increase in PCS to 24 hours/day, 7 days/week (split-shift), for a total of 168 hours/week.
The denial is overturned.

This elderly female has medical conditions including Alzheimer's disease, arthritis, hypertension, gastroesophageal reflux disease (GERD), depression, weakness, chronic pain, diabetes, and anemia. She is appealing the denial of an increase in personal care services (PCS) to 24 hours/day, 7 days/week (split-shift), for a total of 168 hours/week. The plan approved PCS 53 hours/week. 

The medical information is sparse. The daughter asked for increased hours due to memory problems and safety supervision. Uniform Assessment System (UAS) evaluation completed earlier this year showed the patient needs assistance with meal preparation, housekeeping, laundry, shopping, toileting, moving around, dressing, and bathing. The patient's provider notes the patient has worsening memory problems. UAS evaluation completed earlier this year showed moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing medications and finances, bathing, and lower body dressing; extensive assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, and toileting; and limited assistance with bed mobility and eating. The patient ambulates with a walker. She has infrequent bowel and bladder incontinence. A letter from her provider notes the patient has physically and mentally declined. The patient does not have other sensory deficits. She has arthritis affecting mobility. Night-time activity logs show the patient intermittently waking up every two to three hours confused and to go to the bathroom for which she needs assistance. There are a few episodes of falling.

An appeal statement from New York state recommends an increase in hours of care based on change in the patient's condition and the current hours being inadequate to meet the patient's needs. 

A letter from another provider notes the patient has several chronic conditions and is rapidly declining, both physically and mentally. She needs 24/7 care to prevent complications.

The proposed treatment is medically necessary.

PCS 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 PCS 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 is appealing the denial of an increase in PCS to 24 hours/day, 7 days/week (split-shift), for a total of 168 hours/week. The plan approved personal care services 53 hours/week. Additional hours are requested for safety supervision due to cognitive decline. The request was denied based on the UAS evaluation, Hours Evaluation for Paraprofessional Support and Care Management records. The UAS evaluation completed earlier this year showed the patient needs assistance with all activities of daily living (ADLs). The patient has infrequent bowel and bladder incontinence. Appeal statements indicate that the patient's physical and mental conditions are declining. There are nighttime activity logs showing the patient requiring assistance transfers and toileting every two to three hours. The information provided supports the patient is dependent with all ADLs and requires frequent assistance with transfers and toileting. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved PCS 53 hours/week is insufficient to meet the patient's needs for assistance with ADLs. The proposed increase in PCS hours to 24 hours/day, 7 days/week (split-shift), for a total of 168 hours/week is medically necessary.