Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, stroke, peripheral vascular disease
Treatment: Increase Personal Care Aide (PCA) and Consumer 
Directed Personal Assistance Program (CDPAP) Services for a Total Amount of 168 Hours per Week (Split Shift) (PCA Level 2: 12 hours per day - 7 days per week; CDPAP: 12 hours per day 
- 7 days per week)
The insurer denied: Increase Personal Care Aide (PCA) and Consumer Directed Personal Assistance Program (CDPAP) 
Services for a Total Amount of 168 Hours per Week (Split Shift) (PCA Level 2: 12 hours per day - 7 days per week; CDPAP: 12 hours per day - 7 days per week)
The denial is overturned.

This elderly female patient has medical conditions that include dementia, hypertension, stroke with right-sided hemiplegia, and peripheral vascular disease. She lives alone. Her children 
are supportive. The denial of an increase in personal care aide (PCA) and consumer directed personal assistance program (CDPAP) services for a total amount of 168 hours per week (split 
shift) is being appealed. The health plan approved personal care aide 7.5 hours per day- 6 days per week and consumer directed personal assistance program 7.5 hours per day- 1 day per week for a total of 52.5 hours per week. Uniform Assessment System (UAS) evaluation completed 4 months ago shows the patient has moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, phone use, bathing, lower body dressing, and toileting; extensive assistance with personal hygiene, upper body dressing, walking, locomotion, and bed mobility; and limited assistance with eating. The patient is incontinent of bowel and bladder. Compared to Uniform Assessment System completed 5 months ago, there has been a decline with cognition, personal hygiene, toilet use, walking, and locomotion. A letter from the patient's daughter notes that the patient's physical and mental well-being have deteriorated. The patient needs assistance with activities of daily living (ADLs) that extend into the nighttime. A home care worker cannot get a full eight hours of sleep. "It is suggested that repositioning is done every 2 hours." Consistent monitoring is needed for toileting needs. Letters from the Provider report the patient has impaired mobility and needs assistance with activities of daily living. The patient's dementia complicates her ability to comprehend her limitations, leading to falls. She needs supervision to minimize falls. She has a non-healing lumbar fracture. Her toileting needs cannot be scheduled. Another statement reports the patient's condition is deteriorating. 

The requested health service is medically necessary. 

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding. 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. Compared to Uniform Assessment System completed 5 months ago, there has been a decline with cognition, personal hygiene, toilet use, walking, and locomotion. Appeal statements support the patient's need for assistance with all activities of daily living and need for daytime as well as nighttime assistance. A daytime and nighttime log shows the patient receiving assistance every one to two hours with activities of daily living, including repositioning and diaper checks. The information provided shows that this patient has significant limitations in functioning that are rapidly deteriorating. Her needs cannot be met with the currently approved personal care aide/consumer directed personal assistance program hours. The proposed increase in personal care aide and consumer directed personal assistance program services for a total amount of 168 hours per week (split shift) is indicated.