Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, diabetes, arthritis, hypertension, hard of hearing, and coronary artery disease.
Treatment: Increase Personal Care Aide (PCA) Services to a Split Shift for a Total of 168 Hours Per Week.
The insurer denied: Increase Personal Care Aide (PCA) Services to a Split Shift for a Total of 168 Hours Per Week.
The denial is overturned.

The patient is an elderly female. Her conditions include dementia, diabetes, arthritis, hypertension, hard of hearing, and coronary artery disease. Denial of increase personal care aide 
(PCA) services to a split shift for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week.
Uniform Assessment System (UAS) evaluation completed 4 months ago shows severely impaired cognition and functional status requiring maximal to total dependence with all ADLs (activities of daily living). The patient has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline with lower body dressing, toilet use, bathing, and eating. Medical records and appeal statements have been provided. An appeal letter indicates the patient has had an acute decline in her physical and cognitive functioning after hospitalization last year, with toxic encephalopathy secondary to acute cystitis. She lives with her son who can only provide limited support due to work. The patient requires continuous assistance with ADLs (activities of daily living). She is unable to turn and reposition herself at night. A letter from the patient's provider notes that the patient has early-stage rectal cancer and will need excision.

The requested Increase Personal Care Aide (PCA) Services to a Split Shift for a Total of 168 Hours Per Week 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 to a split shift for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week.
This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed 4 months ago shows severely impaired cognition and the need for maximal assistance to total dependence with all ADLs (activities of daily living). The patient is incontinent of bowel and bladder. Compared to UAS (Uniform Assessment System) evaluation completed previously, 
there has been a decline with lower body dressing, toilet use, bathing, and eating. The appeal information supports 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 cannot be met with the approved personal care aide 84 hours per week. The requested increase PCA (personal care aide) services to a split shift for a total of 168 hours per week is medically necessary.