Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia and strokes
Treatment: Increase in Personal Care Aide (PCA) Level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week
The insurer denied the increase in PCA Level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week.
The denial is upheld.

The patient is a female who has multiple medical conditions, including dementia and strokes. Denial of an increase in Personal Care Aide (PCA) Level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week is being appealed. The Plan approved PCA Level 2: 12 hours/day, 5 days/week, CDPAP (consumer directed personal assistance program): 12 hours/day, 2 days/week, for a total of 84 hours/week.

The patient's Uniform Assessment System (UAS) evaluation completed shows the patient has minimally impaired cognition and functional status: total dependence with meal preparation, housework and shopping; maximal assistance with managing medications, bathing, lower body dressing, walking, locomotion, and toileting; and extensive assistance with phone use, personal hygiene, upper body dressing, bed mobility and eating. She has occasional bowel and bladder incontinence. Compared to UAS evaluation completed previously, there has been a functional decline in upper body dressing, locomotion, and bed mobility.

An appeal letter notes multiple chronic conditions, including new stroke with gradual cognitive and functional decline. The letter recommends 24 hour supervision.

An appeal letter notes the patient needs 24 hour supervision to prevent self-harm and falls and to administer medications.

The patient's daughter is requesting additional hours to prevent self-harm and falls. The daughter reports that the patient needs assistance with ambulation and transfers due to generalized weakness. She is no longer able to provide informal support for her mother.

No, the increase in PCA to 24 hours/day, split-shift, is not 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. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Personal Assistance Services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services. Denial of an increase in PCA Level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week is being appealed. The Plan approved PCA Level 2: 12 hours/day, 5 days/week, CDPAP: 12 hours/day, 2 days/week, for a total of 84 hours/week.

This patient has multiple conditions and is noted to have cognitive and physical decline after a stroke earlier in the year. UAS evaluation completed shows the patient requires assistance with all ADLs. She has occasional bowel and bladder incontinence. Appeal statements note that the patient's functional and cognitive status has deteriorated. 24-hour care is recommended for supervision. PCA is not indicted for supervision or when no tasks are being performed. The documentation provided does not support that the patient needs overnight care. The approved PCA hours are appropriate and medically necessary to meets the patient's needs for assistance with ADLs and personal care. The proposed increase in PCA to 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.