Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, coronary artery disease, parathyroid cancer, and osteoarthritis. 
Treatment: Increase PCA (personal care aide) to 2 12- hours split shift, 7 days a week. 
The insurer denied: Increase PCA (personal care aide) to 2 12- hours split shift, 7 days a week. 
The denial is overturned. 

The patient is an elderly female. Her medical conditions include dementia, hypertension, coronary artery disease, parathyroid cancer, and osteoarthritis. Denial of increase PCA (personal care aide) to 2-12 hours split shift, 7 days per week is being appealed. The health plan approved increase to live-in services, 7 days per week. The patient's Uniform Assessment System evaluation completed 6 months ago shows moderately impaired cognition and functional status requires extensive assistance to total dependence with all ADLs (activities of daily living), except limited assistance with eating. She has frequent bladder incontinence. Appeal statements note that the patient is homebound. She has a history of repeated falls, with the most recent one having occurred 6 months ago. She was admitted 5 months ago for urinary tract infection. She needs assistance with ADLs (activities of daily living), including turning/repositioning every two hours. She has urinary incontinence. Her functioning has deteriorated over the prior 90 days, after her recent fall. Night logs shows frequent assistance with toileting. 

The requested Increase PCA (personal care aide) to 2-12 hours split shift, 7 Days/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 PCA (personal care aide) to 2 12-hour split shift, 7 days per week is being appealed. The health plan approved increase to live-in services, 7 days per week. This patient has multiple chronic conditions. She was recently hospitalized with a urinary tract infection. Uniform Assessment System (UAS) evaluation completed 6 months ago showed the patient requires extensive assistance to total dependence with all ADLs (activities of daily living), except limited assistance with eating. She has frequent bladder incontinence. Appeal statements report that the patient has repeated falls. There has been a deterioration since her fall 6 months ago. She needs assistance with ADLs (activities of daily living), including turning/repositioning every two hours. The provided night log supports frequent assistance with toileting. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved PCA (personal care aide) live-in services, 7 days per week is insufficient to meet the patient's continuous needs. The requested increase personal care aide to 2-12 hours split shift, 7 days per week is medically necessary.