Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Parkinson's Disease. 
Treatment: Home health Care. 

The health plan denied the requested PCA services. 
The health plan's determination is upheld. 

The patient is a male with a past medical history significant for neck, thoracic and low back pain, bilateral lower extremity pain, sciatica, left hip pain, left knee pain, insomnia, Parkinson's disease, dizziness, vertigo, headache, urinary incontinence, hemorrhoids, blurry vision, bilateral lower extremity edema, anxiety, dementia, and depression. 
24 hours a day services, 12 hours per day 2 split shift personal care assistant (PCA) services are requested. The plan just approved live-in 24/7 PCA services.
At issue is the medical necessity of the requested Increase in Personal Care Aide-7 days x 12 hours x 2 shifts in PCA services. 

The health plan's determination of medical necessity is upheld, in whole. 

No, the requested health service of an increase in Personal Care Aide-7 days x 12 hours x 2 shifts is not medically necessary for this patient. 

The patient is an elderly male with progressive physical and cognitive decline. He is noted to be bedbound after a recent nursing home stay. The patient has had a decline in his physical ability since the last evaluation on the Uniform Assessment System (UAS).
Statements from the patient's physician were reviewed. These note the patient's physical decline and the need for additional homecare services, specifically noting that the patient is now bed bound requiring more services. Specifically, being requested are additional services for nighttime with changing of diapers to prevent skin break down and urinary infections. This is a common issue with patients at this stage of life and associated comorbidities, which can be addressed by incontinence products, which are provided. Typically, if a patient has an active ulcer in the sacral area, positioning should be done on a frequent basis while the patient is recumbent, however there is no mention of this in the medical record in regard to active treatment of an ulcerated lesion in the sacrum. Other issues mention recurrent falls and watching the patient to prevent falls is included in the time allotted in the calculation of the services being provided.
Services for preventing falls and observation are typically included in the provided services allowed for under the evaluation. Specifically, the aide must be performing a service such as in activities of daily living (ADL) or instrumental activities of daily living (IADL) to be a covered service. Aide services for watching the patient in the middle of the night without actually performing a medically necessary ADL would be considered observation and typically not a service provided. There is no nighttime log provided for review. Specifically, there is no documented nighttime need necessitating split shift services. The documentation provided did not note specific needs for 12 hour a day 7 days a week split shift. 
There must be a documented significant change in functional status requiring additional time and assistance to complete instrumental activities of daily living. Based upon review of the clinic record recent care management documentation on the UAS survey, I recommend the continuation of the currently approved 24/7 PCA live-in services. There is no documented need noted for 12 hours per day 2 split shift services.