Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, osteoarthritis, hypertension, heart failure, and diabetes
Treatment: Increase Personal Care Aide (PCA) Services to a Split Shift for a Total Amount of 168 Hours Per Week
The insurer denied: Increase Personal Care Aide (PCA) Services to a Split Shift for a Total Amount of 168 Hours Per Week
The denial is overturned.

The patient is an elderly female. Her conditions include Alzheimer's disease, osteoarthritis, hypertension, heart failure, and diabetes. This is an appeal for denial of increase personal care aide (PCA) services to a split shift for a total amount of 168 hours per week. The health plan approved 25 hours per week.
Uniform Assessment System (UAS) evaluation completed recently shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, shopping, bathing, lower body dressing, walking, and locomotion; maximal assistance with phone use, personal hygiene, upper body dressing, toileting, and bed mobility; and limited assistance with eating. The patient has occasional bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline in functioning with dressing, personal hygiene, toileting, bathing, walking, locomotion, eating, and bed mobility. Appeal statements from advocates and medical providers indicate that the patient needs assistance with all ADLs (activities of daily living). She has deteriorated after having recently suffered a broken leg. She has frequent urination due to diuretic medication. She regularly needs to be changed during the day and night. She needs to be repositioned every two hours. There are nighttime logs supporting frequent diaper change, transferring, and turning throughout the night.

The requested Increase Personal Care Aide (PCA) Services to a Split Shift for a Total Amount of 168 Hours Per Week is medically necessary.

Personal care service 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 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 is an appeal for denial of increase personal care aide (PCA) services to a split shift for a total amount of 168 hours per week. The health plan approved 25 hours per week. This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed recently shows the patient requires maximal assistance to total dependence with all ADLs (activities of daily living), except limited assistance with eating. She has occasional bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline in functioning with dressing, personal hygiene, toileting, bathing, walking, locomotion, eating, and bed mobility. The appeal statements support that the patient is dependent with all ADLs (activities of daily living) and requires frequent assistance with toileting and transfers. She requires turning/repositioning every two hours. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested increate in PCA (personal care aide) services to a split shift for a total amount of 168 hours per week is medically necessary.