Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, hypothyroidism, osteoarthritis, dementia 

Treatment: Increase in personal care assistant (PCA) services from 7 days x 12 hours (84 hours per week) to 24 hours a day, 7 days a week (split shift)

The insurer denied coverage for an increase in personal care assistant (PCA) services from 7 days x 12 hours (84 hours per week) to 24 hours a day, 7 days a week (split shift).

The denial is overturned.

This patient has cognitive and physical impairment and requires substantial assistance for all daily activities. The patient lives alone in an independent living facility with occasional oversight by staff. The patient needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). In addition to the services provided by the assisted/independent living facility, the patient has personal care assistant (PCA) services 12 hours per day. The patient's family member (patient designee) requested increase of services to continuous split shift. 

The most recent uniform assessment system (UAS) provided for review indicates the patient is totally dependent on caregiver assistance for IADLs except managing medications and phone use (extensive assistance). For ADLs, the patient is totally dependent for lower body dressing; she needs maximal assistance for bathing, locomotion, transfer toilet and toilet use; extensive assistance for upper body dressing and bed mobility; limited assistance for personal hygiene; setup help for eating. The patient has become wheelchair dependent due to progressive degenerative disease of her hips and knees. The UAS noted the patient has knee pain due to osteoarthritis. It is also noted the patient is bathed by bed bath suggesting patient may not be able to transfer to shower due to poor mobility.

The records indicate some degree of cognitive impairment. Per a family member, the patient has dementia which mostly involved short term memory loss until recently and has since rapidly progressed. She has intermittent but frequent periods of disorientation; she becomes distressed and does not cooperate with her aides. A family member reported medication has been prescribed which has helped, but the efficacy has diminished over time. They have observed that the patient forgets where she is; imagines she has been kidnapped; she becomes more anxious and confused. She tried to climb out of bed at night (risk of falls). Similar reports of the patient's behavior were noted in the physician's notes who recommended around the clock care.

MLTC (Managed Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. When the patient needs assistance with toileting or incontinence care; repositioning in bed for pressure relief; assistance with mobility when she wants to get out of bed, this is not stand-alone safety supervision. Caregiver assistance is medically necessary for effective and safe completion of these ADLs which can occur at unscheduled and recurring times throughout the day and night.  A caregiver can help prevent adverse health and safety events and help facilitate comfort/pain relief. These care needs must be considered in the determination of the patient's personal care service hours. 

Considering the patient's medical history and functional impairment, it is medically necessary, and in the patient's best interest to have a caregiver present to help with all ADLs and IADLs that occur throughout the day and night. It does not appear her care needs can be adequately and safely met within the service hours provided by a live-in aide. Therefore, continuous personal care services (split shift) are indicated.

The insurer's denial of coverage for an increase in personal care assistant (PCA) services from 7 days x 12 hours (84 hours per week) to 24 hours a day, 7 days a week (split shift) is overturned. Medical Necessity is substantiated.