Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia.
Treatment: Personal care aide level 2: 12 hours per day- 7 days per week (split shift) - a total of 168 hours per week.
The insurer denied personal care aide level 2: 12 hours per day- 7 days per week (split shift) - a total of 168 hours per week.
The determination is upheld.


The patient has a past medical history significant for dementia, aortic stenosis, vitamin D deficiency, and dyslipidemia. Additional services, 12 hours per day 7 days a week split shift for a total of 168 hours a week are requested. The patient is currently approved for 66.5 hours per week.
At issue is the medical necessity of personal care aide level 2: 12 hours per day- 7 days per week (split shift) - a total of 168 hours per week medically necessary for this patient.

The requested health service is not medically necessary for this patient.
The health plan approved 9.5 hours per day 7 days a week for total of 66.5 hours per week. The request was from the patient's daughter who requested additional assistance due to Alzheimer's disease and assistance with bathing, personal hygiene, dressing, feeding, meal preparation and walking. The patient is able to walk with the assistance of a walker. Time has been allotted for meal preparation. Her daughter directs her care and is supportive.
The Uniform Assessment System (UAS) State of New York was reviewed. The patient resides in a 1 bedroom apartment located in her daughter's house. She is total assistance for Instrumental activities of daily living (IADLs). The patient requires maximal assistance for most other activities.
Hospitalization was noted for weakness diagnosed with encephalopathy and treated for urinary tract infection.
The UAS State of New York was reviewed. The statement from the patient's physician recommended 12 hours per day of services times () 7 days a week
The physician notes from Dr. Stephen McCormick were reviewed.
The patient has with multiple medical problems with progressive memory loss from Alzheimer's disease and functional decline. The patient is dependent upon caregivers for all activities of daily living (ADLs) and ADLs. The UAS evaluation account for her scheduled needs which include feeding, bathing, dressing and toileting. However with progressive Alzheimer's disease and generalized functional decline the patient's unscheduled needs may become more apparent, specifically continence issues and generalized mobility. It is reasonable say that the patient does need more services, however, split shift 12 hours 2 per day 7 days a week are not medically necessary. There were no reports or other documentation provided to delineate the need for nocturnal services by a PCA, such as nighttime log or specific recommendations for her physician for turning for a bedsore. 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 ADL or 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 under the terms of the plan. The documentation provided did not note specific needs for 12 hour a day 7 days a week split shift.