Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Coronary artery Disease/CAD
Treatment: Home heath care/168 hours/week, 12 Hours x 2 x 7 Days-Split Shift; Personal Care Aide-Level 2.
The health plan denied the requested 168 hours/week, 12 Hours x 2 x 7 Days-Split Shift; Personal Care Aide-Level 2 as not medically necessary. 
The health plan's determination is upheld.

This is a case review for a female with a medical history notable for dementia, coronary artery disease, and diabetes. The patient is approved for 18 hours per day, 7 days per week (126 hours per week) of level 2 personal care aide (PCA) services. The patient and her care team requested an increase to 2-12-hour split-shift care, 7 days per week (168 hours per week) and this request was denied by the health plan. This denial is the subject under review.
The patient's caseworker provided a letter of support for this appeal. The letter states that the patient does not sleep for more than an hour or two at a time due to her advanced dementia. If she does not have assistance, she will forget that she cannot walk alone and is at risk of falls. A live-in personal care aide is required to get a minimum of 5 hours of rest at night, and this would not be possible given the patient's current needs.
The physician who is caring for the patient at a nursing facility provided a letter of support for this appeal. The letter describes her current need for assistance. It states that she "would benefit from 12/12 split-shift Home Health Aid (HHA) services secondary to her medical complexity. This would greatly assist with her transition in the community."
A nighttime log was provided for review. The review describes that the patient attempts to toilet 1-3 times overnight. There are numerous documented attempts after midnight.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in-person at the adult day care health program. The patient was oriented to person only. Short term memory and procedural memory was not intact. She is not able to direct her own care. For her instrumental activities of daily living (IADL), she requires total dependence for housework, transportation and stairs. She requires maximal assistance for meal preparation, finances, and shopping. For her activities of daily living (ADL), she requires total dependence for locomotion. She requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, walking, and eating. She is frequently incontinent of urine with some control present. She uses 1-3 diapers per day. She has an ostomy in place for stool.
At issue is the medical necessity for the requested health service/treatment of 12 Hours x 2 x 7 Days-Split Shift; Personal Care Aide-Level 2.

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

The requested health service of 12 Hours x 2 x 7 Days-Split Shift; Personal Care Aide-Level 2 has not been demonstrated to be medically necessary for this patient.
The patient has dementia and requires assistance with numerous ADL's and IADL's. The plan approved her for assistance 18 hours per day, and the patient's care team requested an increase to 24 hours per day, The question at hand is whether or not there is clearly documented evidence of medical necessity that the patient requires personal care assistance for those additional six hours of overnight care. There is no documented need for diaper changes or turning/repositioning to help a pressure ulcer. There is documentation that the patient often tries to get out of bed due to her dementia; however, monitoring for these behaviors is not a covered personal care function. Therefore, there is no clear medical necessity for the requested increase in hours.