Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cognitive decline
Treatment: Personal care services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours.
The insurer denied personal care services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours.
The health plan's determination is upheld.


The patient has a past medical history of diabetes mellitus type 2, congestive heart failure, age-related cognitive decline, deep vein thrombosis (DVT), gastroesophageal reflux disease (GERD), glaucoma, permanent pacemaker, hypertension, hyperlipidemia, osteoporosis, chronic anticoagulation, urinary incontinence, and bowel incontinence who had been assigned personal care assistant (PCA) services. There was a request to increase services and the patient underwent an assessment tool via telehealth assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, and locomotion while maximum assistance with tasks of transportation, bathing, dressing lower body, transfer toilet, and toilet use. With the tasks of managing medication, phone use, personal hygiene, dressing upper body, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. For the task of walking it was noted activity did not occur as patient was unable to ambulate. Notes from the assessment stated the patient is unable to activate the personal emergency response system (PERS), required to be changed 1-2 times per night, utilized a wheelchair and scooter for ambulation, had a decline in activities of daily living (ADL) status over the preceding 90 days, and deterioration in overall self-sufficiency over the last 90 days.
The insurer sent an initial adverse determination denial notice denying the request to increase PCA services. The denial stated the patient's daughter reported that the patient needed help with toileting and positioning at night, the plan recommended splitting her hours into 2 shifts as this would meet the patient's morning and evening needs, the plan recommended limiting fluids after 6 PM to reduce nighttime urination, the plan recommended a pressure reducing mattress, and noted hours for safety and supervision were not covered benefit.
The patient appealed the denial decision with the statement that the patient was approved for 24-hour services live-in, but there was no agency that could accommodate the request and so the family was requesting 12-hour, split shift, 7 days a week and would use CDPA [Consumer Directed Personal Assistance] if the agency could not support the patient's needs. The insurer sent a final adverse determination denial notice denying the request to increase PCA services.
At issue is the medical necessity of personal care services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours.
The services are not medically necessary.
The universal assessment noted the patient is up 1-2 times per night with assistance needs which would allow a PCA the ability to sleep 5 hours. There is no documentation from a medical provider of the medical necessity of frequent turning and repositioning. The family has had difficulty finding an agency that could accommodate a 24-hour live-in aide but could split current hours to meet the patient's daytime and nighttime needs. 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 24 hours/day, split-shift, 7 days/week, to total 168 hours week are not medically necessary for this patient.