Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, coronary artery disease, anxiety, dementia, and insomnia
Treatment: Increase Personal Care Aide (PCA)Services Level 2: 12 hours per day -7days a week; 12 hours per day - 7 days a week (split shift)- For A Total of 168 Hours Per Week
The insurer denied: Increase Personal Care Aide (PCA)Services Level 2: 12 hours per day -7days a week; 12 hours per day - 7 days a week (split shift)- For A Total of 168 Hours Per Week
The denial is Overturned.

The patient is an elderly female. His conditions include hypertension, coronary artery disease, anxiety, dementia, and insomnia. Denial of Increase personal care aide (PCA) services, 12 hours per day, 7 days a week (split shift) for a total of 168 hours per week is being appealed. The plan approved PCA (personal care aide) 10.5 hours per day, 7 days a week for a total of 73.5 hours per week.
The patient's Uniform Assessment System (UAS) evaluation completed a few months  ago, shows severely impaired cognition and functional status maximal assistance to total dependence with all ADLs (activities of daily living). The patient is incontinent of bowel and bladder. A letter from the patient's provider notes that the patient is bedbound and non-ambulatory. She is dependent with all ADLs (activities of daily living) and needs supervision at all times. She requires frequent repositioning in bed and frequent diaper changes. A letter from the patient's daughter notes the patient is bedbound. She has to be supervised. She has bed sores and needs assistance with repositioning during the night.

The requested increase in Personal Care Aide services to 168 hours per week, split shift, 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. Denial of Increase personal care aide (PCA) services, 12 hours per day, 7 days a week (split shift) for a total of 168 hours per week is being appealed. The plan approved PCA (personal care aide) 10.5 hours per day, 7 days a week for a total of 73.5 hours per week.
This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed a few months ago, shows severely impaired cognition and functional status maximal assistance to total dependence with all ADLs (activities of daily living). She is incontinent of bowel and bladder. The appeal statements support the patient is dependent with all ADLs (activities of daily living) and requires frequent assistance with toileting, transfers, and turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved PCA (personal are aide) 10.5 hours per day, 7 days a week for 
a total of 73.5 hours per week is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living). The requested PCA (personal care aide) services, 12 hours per day, 7days a week (split shift) for a total of 168 hours per week is medically necessary.