Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bedbound. 
Treatment: Personal care aid (PCA) level 2 services- 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week. 

The insurer denied personal care aid (PCA) level 2 services- 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week. 

The determination is upheld. 

This is a male patient with a medical history notable for bedbound status. The patient is approved for 24 hours per day live-in personal care services. The patient and his care team requested an increase to 2-12 hour split-shift (168 hours per week), and this request was denied by the health plan. 

The patient's physician provided a letter of support for this appeal. The letter states that the patient is declining. He is "mostly bed-bound, with worsening dementia and cognitive functions, general weakness, incontinence, and unable to perform any activities of daily living (ADLs) without help." The physician requested around-the-clock care for the patient. 

The request for split-shift care was submitted by the patient's son. The patient's wife passed away recently (they had been a mutual case), and he now lives alone with no one to informally assist with his care. He is bed bound, has dementia, and has urinary and stool incontinence. 

A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted via teleconference. The patient's cognition was severely impaired. He was disoriented to person, place, and time. He cannot direct his own care. For his Instrumental activities of daily living (IADLs), he requires total dependence for meal preparation, housework, finances, medications, phone use, stairs, shopping, and transportation. For his ADLs, he requires total dependence for bathing, hygiene, dressing, toilet use, and eating. He requires maximal assistance for bed mobility. He is incontinent of stool and urine and unable to toilet at all; all toileting is done in a diaper. He requires significant weight-bearing assistance for repositioning in bed. Compared to a prior UAS, he showed a decline in toileting and incontinence. At issue is the medical necessity of personal care aid (PCA) level 2 services- 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week. 

The requested health service of personal care aid (PCA) level 2 services- 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week has not been clearly demonstrated to be medically necessary for this patient. 

The patient's health plan did not approve the increase to split-shift care, but they did approve 24-hour live-in care. Live-in personal aides are expected to be able to rest at night with at least a 5 hour period of uninterrupted rest each night. If this requirement cannot be met, then split-shift services are medically necessary. 

In this case, there is no clearly demonstrated personal care need that would preclude rest overnight for the live-in aide. The patient does require assistance with diaper changes, but there is no nighttime log of the frequency of these changes. He needs assistance with repositioning in bed but does not have any active pressure ulcerations. It has not been clearly demonstrated to be medically necessary to increase the services from live-in to split-shift level personal care.