Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease, idiopathic progressive neuropathy
Treatment: Personal Care Assistance services 24 hours per day, 7 days per week (split-shift)
The insurer denied Personal Care Assistance services 24 hours per day, 7 days per week (split-shift).
The determination is upheld.

This is a female patient with a history of coronary artery disease, hypertension, Parkinson's disease, idiopathic progressive neuropathy, unsteadiness on feet, generalized weakness, urinary incontinence, bowel incontinence, gastroesophageal reflux disease (GERD), anxiety, depression, and insomnia. The patient was previously approved for Personal Care Assistance services 51 hours per week. The patient and her care team requested Personal Care Assistance services 24 hours per day, 7 days per week (split-shift); this request was denied by the Plan.
An in-person Uniform Assessment System (UAS) was completed.  A tasking tool was used to determine that she requires 30.04 hours of aide service per week.
Another in-person UAS was completed. The patient was assessed at maximal assistance for the tasks of ordinary housework, stairs, shopping, transportation, bathing, dressing upper body, dressing lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility; extensive assistance for the tasks of meal preparation, managing finances, managing medications, personal hygiene, and eating; and independent for phone use. Per the assessor, the patient's activities of daily living (ADL) status has declined and overall self-sufficiency has deteriorated in the past 90 days. She has durable medical equipment at home of a commode, rollator, wheelchair, shower chair, grab bars, and toilet frame. A tasking tool was used to determine that she requires 60.71 hours of aide service per week. At issue is the medical necessity of Personal Care Assistance services, 24 hours (hrs) per day, 7 days per week (split-shift).

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, Personal Care Assistance services, 24 hours per day, 7 days per week (split-shift) is not medically necessary.
Per New York Codes, Rules, and Regulations section 505.14, a live-in personal care aide (PCA) must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. Split-shift care requires proof that a personal care assistant (PCA) would be unable to receive 5 hours of uninterrupted rest. While the patient requires hands-on assistance for many ADLs and Instrumental activities of daily living (IADLs), and the Uniform Assessment System (UAS) does reflect a decline in ADL status as compared to the last UAS, there is no documentation showing that patient currently requires frequent care overnight. There were no night-logs of care required overnight and no physician orders for frequent repositioning. The information provided did not indicate whether the patient's home has space for a PCA to receive 8 hours of sleep per night. Therefore, there is insufficient evidence of medical necessity for the requested increase in PCA hours. Additional hours are not provided when tasks are not being performed and for safety monitoring and supervision only.