Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Personal care worker (PCW) 12x12 hours (split shift) per day, 7 days per week
The insurer denied Personal care worker (PCW) 12x12 hours (split shift) per day, 7 days per week.
The determination is upheld.

The patient has a past medical history of hypertension, coronary artery disease, atrial fibrillation on long term anticoagulation, permanent pacemaker, diastolic heart failure, dementia, incontinence of urine, incontinence of bowel, aspiration, diabetes mellitus type 2 with long term insulin use, and dementia who had been assigned personal care assistant (PCA) services 24 hours/day, live-in, 7 days/week approved. The patient had a hospitalization for heart block and pneumonia and for congestive heart failure. There was a request to increase PCA service hours to 12 x 12 hours (split shift)/day, 7 days per week. The patient had an assessment tool performed stating the patient was not able to walk since hospitalization and the death of her spouse and required wheelchair transport and help with transfers. In addition, since the hospitalizations, the patient had to be spoon fed a pureed diet with thickened liquids. The assessment noted the patient lives alone, was alert and oriented times (x) 1, and was pleasant during the first 15 minutes of the assessment but then became angry with screaming when aide tried to change her diaper with daughter reporting the patient's functional and mental status had deteriorated since the patient's husband's death and the hospitalizations. The patient was assessed at total assistance for all tasks except bed mobility and eating which were assessed at maximal assistance. The patient was enrolled on hospice as noted by assessment which stated the patient was very confused, had pain in hips and back, had shuffling gait, was chairbound, required assistance with toileting, needed assistance with bathing, dressing, grooming, toileting, housekeeping, shopping, and meal prep, had agitation and restlessness at times, and the patient was still under the care of her cardiologist and psychiatrist.
The plan provided a final adverse determination notice denying coverage for the request for PCA services 12 x 12 hours (split shift)/day, 7 days/week. This denial notice stated the patient was alert and able to direct her care, had no change in needs for assistance with bathing, personal hygiene, dressing, walking, locomotion, toilet transfer, and toilet use since the last assessment, was able to take medication with reminders from her aide, was receiving registered nurse (RN) and visiting nurse services (VNS)/ hospice services, and coverage did not include safety supervision separate from personal care tasks. The patient's family appealed this denial. The daughter provided a letter of support for increased PCA service hours stating the patient is diabetic with the need for around the clock monitoring of glucose levels, receives insulin injections night and day depending on glucose levels, needs to be fed Glucerna if blood sugar is low, is incapable of walking to the bathroom or cleaning herself after using the bathroom, stays up many hours of the night, cannot feed herself nor take care of her bodily needs, and has an overall decline in her health since recent hospitalizations. The daughter's letter noted inaccuracies of the patient's assessment tool specifically citing cognitive skills are significantly impaired and not moderately impaired, is unintelligible with her speech and not often understood, is not able to be transported in any vehicle, except ambulance type, and is not able to tolerate normal transportation needs, had falls during her hospital stay but the report noted no recent falls. In addition, the daughter's letter stated the patient had paranoia and delusions but the report noted the patient to have no delusions. The patient's primary care physician (PCP) provided a letter stating the patient has recently deteriorated substantially and specifically has become a brittle diabetic with widely fluctuating glucose results necessitating frequent around the clock monitoring, requiring a split shift 12 hour home health aide as she needs to be tested frequently to prevent severe hypoglycemia. At issue is the medical necessity of PCA 12x12 hours (split shift) per day, 7 days per week
The requested services are not medically necessary. The patient had PCA services 24 hours/day, live-in, 7 days/week. The patient had worsening functional and mental status following the death of her husband and her two hospitalizations. The patient did not have documented unscheduled or unpredictable care needs. The patient did not require turning and positioning every two hours. The patient's medical provider cited the medical necessity for increased PCA care needs to be the need for frequent and around the clock monitoring of her blood sugars. Blood glucose checking and administration of insulin are out of the scope of practice for Level I and II PCA service aides. PCA services are not for safety monitoring and supervision but to assist the patient with specific activities of daily living (ADL) and instrumental activities of daily living (IADL) tasks. The information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guideline do not support the medical necessity for PCA services 12 x 12 (split shift)/day, 7 days/week.