Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's dementia
Treatment: Personal Care Aide (PCA) services for a total amount of 168 hours per week (split-shift)
The insurer denied Personal Care Aide (PCA) services for a total amount of 168 hours per week (split-shift).
The determination is upheld.

The patient is a male  with past medical history of lymphoma, thrombocytopenia, atrial fibrillation, permanent pacemaker status, Alzheimer's dementia, bowel incontinence, and urinary incontinence who had been assigned personal care assistant (PCA) services based on an assessment tool. The patient had a hemorrhagic cerebrovascular accident (CVA) and there was a request to increase PCA services and the patient underwent another assessment. The patient was assigned PCA services 10-1/2 hours a day, 7 days/week, to total 73.5 hours/week.
The patient's primary care physician (or provider) (PCP) provided a letter stating the patient needed around-the-clock supervision due to his deteriorating condition and the patient's current hours left the patient alone all night and the provider recommended two 12-hour shifts 7 days a week. The patient underwent another assessment assessing the patient at total assistance with all tasks except for walking, locomotion, bed mobility, and eating for which he was assessed at maximum assistance. The insurer sent a final adverse determination denial notice partially approving request to increase PCA services by approving 12 hours/day, 7 days/week, to total 84 hours/week. The denial also stated granting additional hours were not provided when tasks were not being performed and for safety monitoring and supervision. The patient's PCP provided a letter stating the patient was homebound and total care with activities of daily living (ADLs). The letter also stated the patient needed around-the-clock care and should have 24 hours / 7 days a week because the patient cannot be alone and he wakes up at night. The daughter provided a letter noting the patient's wife who  provided companionship and assistance in preparing meals passed away. The letter also stated the patient lived alone and was cared for by a patchwork of aids that provided care from 8 AM to 8 PM and this was not enough as the patient had fecal and urinary incontinence and experienced bouts of sundowning syndrome. At issue is he medical necessity of Personal Care Aide (PCA) services for a total amount of 168 hours per week (split-shift). 
The services are not medically necessary. Although there is a request by the patient's medical providers for increased services there is no documentation of medical necessity of split shift services. There are no overnight care needs documenting that a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. There are no overnight care logs provided documenting specific overnight ADL care needs at specific intervals that would make split-shift services medically necessary. There is no documentation of the need for turning and repositioning every two hours in the overnight hours. There is no documentation that the patient's home is unable to accommodate a live-in PCA. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 168 hours/week (split-shift) are not medically necessary for this patient.