Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia and impaired mobility.
Treatment: Personal Care Aide (PCA) Services: 12 Hours per Day - 7 Days per Week; 12 Hours per Day - 7 Days per Week; Total of 168 Hours per Week (Split Shift).
The insurer denied the Personal Care Aide (PCA) Services: 12 Hours per Day - 7 Days per Week; 12 Hours per Day - 7 Days per Week; Total of 168 Hours per Week (Split Shift).
The denial is upheld. 

This patient is a female with medical conditions including coronary artery disease (CAD), hypertension, cerebral vascular accident (CVA), gastroesophageal reflux disease (GERD), dementia and depression.  She is appealing denial of personal care aide (PCA) 168 hours per week, split shift.  She has been approved for 59.5 hours per week.  

The patient lives in a one bedroom apartment.  Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, and shopping; maximal assistance phone use, stairs, transportation, bathing, personal hygiene, dressing, toilet transfer and toilet use; extensive assistance with walking, and locomotion; and supervision with bed mobility and eating.  She is able to ambulate with a walker.  Durable medical equipment (DME) includes a bedside commode, shower chair and walker.  She has bowel and bladder incontinence.  The patient sleeps during the day and is awake at night.  Compared to Uniform Assessment System (UAS) evaluation performed five months prior, it shows a decline in managing finances and medications, walking, locomotion, toileting, bed mobility and eating. 

An appeal statement from New York State notes that the patient's physical condition has deteriorated in recent months with worsened gait.  She has sustained several falls resulting in subarachnoid hemorrhage and hospitalization.  The appeal notes the patient now needs personal care the entire day and night. A statement from nurse practitioner (NP) Ramdhanny recommends 12 hours split shift care as the patient is actively climbing out of the bed at night.  A letter from the patient's sister notes that between the hours of 7PM and 10PM, the patient is yelling trying to get out of bed.

No, the proposed treatment is not medically necessary.
The proposed treatment is not medically necessary because it is not consistent with standard of care.

This patient has multiple chronic conditions including dementia and impaired mobility.  The denied personal care aide (PCA) 168 hours per week is being appealed.  The patient has been approved for 59.5 hours per week.  

Personal assistance services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  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 provider five hours daily of uninterrupted sleep during the aide's shift.  

The Uniform Assessment System (UAS) evaluation performed shows the patient requires assistance with meal preparation, housework, managing finances and medications, shopping, phone use, stairs, transportation, bathing, personal hygiene, dressing, toilet transfer, toilet use, walking, and locomotion.  Compared to Uniform Assessment System (UAS) evaluation performed five months prior, it shows decline in managing finances and medications, walking, locomotion, toileting, bed mobility and eating.  The patient has bowel and bladder incontinence.  Appeal statements note that the patient's medical condition has deteriorated.  She had falls with one hospitalization as a result of a fall.  Appeal statements are recommending 24-hour, split shift care to manage the patient while she is awake at night and trying to get out of the bed.  Personal care aide (PCA) services are not indicated for supervision as requested for the patient who is noted to be yelling and trying to get out of bed at nighttime.  The documentation does not support that there are tasks to be performed at nighttime.  This patient does not have the need for hands-on assistance 24 hours per day.  The approved personal care aide (PCA) 59.5 hours per week is sufficient to provide assistance with activities of daily living (ADLs) and personal care as noted above.  The proposed increase in personal care aide (PCA) 24 hours per day, split shift is not medically necessary.