Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vison. 
Treatment: Home Health Care. 
The insurer denied personal care assistance services 24 hours a day split shift. 
The denial is upheld.

The patient is a female with a past medical history of diabetes mellitus type 2, hearing loss, glaucoma, Charles Bonnet Syndrome (visual impairment/blindness with hallucinations), urinary incontinence, bowel incontinence, wheelchair bound, osteoarthritis, transient ischemic attacks (TIAs), stage four (IV) avascular necrosis, and probable Lewy body dementia, who had been assigned Personal Care Assistance (PCA) services 70 hours/week based on assessment tool. At this assessment, the patient was assessed at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, and toilet use while maximum assistance with tasks of managing medication, transportation, equipment management, bathing, dressing upper/lower body, and locomotion. The patient was assessed at extensive assistance with tasks of phone use and personal hygiene while limited assistance with tasks of bed mobility and eating. It was noted that activities of stairs, equipment management, walking and transfer toilet did not occur during the assessment.

The patient had annual wellness checkup noting her diagnoses of Lewy body dementia, severe left hip and low back pain, and legal blindness.  The patient's ophthalmologist provided a letter documenting the patient's ophthalmology diagnoses. There was a request to increase PCA services and the patient underwent a telephonic assessment assessing the patient at total assistance with meal preparation, ordinary housework, managing finances, phone use, stairs, shopping, equipment management, locomotion and toilet use while maximum assistance with tasks of managing medication, transportation, bathing, personal hygiene, and dressing upper/lower body. Notes from the assessment stated the patient lived alone in an apartment, had a decline in memory, had a daughter that lives 1-1/2 hours away with a varied schedule with her job, is unable to stand to transfer out of bed to chair and is transferred by lifting hold position with chair next to bed, is assisted into the shower by personal care aide using a shower bench, personal care aide bathes and dresses her, is sometimes able to assist with commands of raising the arms or lifting the legs and other times is confused and has to have it done for her, is fed due to blindness and carpal tunnel, and due to confusion, blindness, and carpal tunnel syndrome is unable to perform activities of daily living (ADLs)/Instrumental activities of daily living (IADLs) on her own. The subject under review is the medical necessity for the increase in services to 24 hours a day split shift. 

The plan partially denied request to approve home care services by increasing PCA services from 70 hours per week to 24 hours/day, live-in, 7 days/week. The patient does have urinary and bowel incontinence with the need to change diapers in the day and night time hours but there is no documentation of this need occurring in a time-frame that would not allow a personal care aide  5 hours of uninterrupted sleep. There is no documentation of medical necessity of repositioning and turning every two hours. The patient doesn't have documented skin breakdown or pressure sores. The PCP letter stated, "most importantly, due to her hallucinations, she requires supervision at night to prevent falls". Without documentation of significant overnight needs with assistance with ADLs, the increase in PCA services from 24 hours/day, live-in to 24 hours/day, split-shift would not be medically necessary.