Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, coronary artery disease, depression
Treatment: Personal Care Aide (PCA) 24 Hours a Day (12x12 
Split Shift), 7 Days a Week
The insurer denied: Personal Care Aide (PCA) 24 Hours a Day (12x12 Split Shift), 7 Days a Week
The denial is overturned.

This is an elderly female patient has medical conditions that include dementia, coronary artery disease, depression, osteoarthritis, lumbar radiculopathy, and diabetes. The denial of personal care aide (PCA) 24 hours a day (12x12 split shift), 7 days a week, is being appealed. The health plan approved personal care aide (PCA) services 8 hours per day, 7 days per week. Uniform Assessment System (UAS) evaluation completed last month shows minimally impaired cognition and functional status requires extensive assistance to total dependence with 
all activities of daily living (ADLs), except limited assistance with bed mobility and supervision with eating. The patient has frequent bladder incontinence. Her condition has declined after the last 2 hospitalizations 2 months ago due to fecal incontinence. A letter from the Provider reports the patient's medical, mental, and functional condition have significantly deteriorated. She is less capable to ambulate and perform activities of daily living since hospitalization. She needs assistance with activities of daily living and has frequent urination/incontinence requiring toileting every 2-3 hours. She requires constant supervision. 

The requested health service is medically necessary.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, 
walking, transfers, turning/positioning, or feeding. 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, including recent hospitalizations for fecal impaction. The denial of personal care aide (PCA) 24 hours a day (12x12 split shift), 7 days a week is being appealed. The health plan approved personal care aide services 8 hours per day, 7 days per week. The health plan denied the requested hours because the services are not indicated for safety supervision. Uniform Assessment System (UAS) evaluation completed last month shows the patient requires extensive assistance to total dependence with all activities of daily living, except limited assistance with bed mobility and supervision with eating. She has frequent bladder incontinence. Her condition has declined since hospitalizations. The appeal statement from the patient's provider reports the patient is less capable to ambulate and perform activities of daily living since hospitalization. Due to urinary urgency and incontinence, the patient requires assistance with toileting every 2-3 hours as well as constant supervision. It is noted that the patient needs supervision, but the appeal statement supports the patient needs increased hours for assistance with activities of daily living that include frequent toileting during the nighttime. The currently approved personal care aide services 8 hours per day, 7 days per week is inadequate to meet this patient's needs for assistance with activities of daily living. The requested of an increase to 24 hours a day (12x12 split shift), 7 days a week is indicated.