Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, oxygen dependent COPD
Treatment: 24 Hours per Week - Split Shift - Personal Care Aide Level II PCS Level II Basic- 15 Minutes
The insurer denied the 24 Hours per Week - Split Shift - Personal Care Aide Level II PCS Level II Basic- 15 Minutes
The denial is overturned.

This male has conditions including dementia, oxygen dependent COPD (chronic obstructive pulmonary disease), heart failure, arthritis, hypertension, sacral ulcer and diabetes.  He lives alone. He is appealing denial of 24 hours per day, split shift - Personal Care Aide.  The plan has approved 12 hour per day, 84 hours per week.  His daughter has been providing informal support but is moving.  An appeal notes that comparative review of the two most recent evaluations do not support decline in the member's ADLs/IADLs (activities of daily living/instrumental activities of daily living). UAS (Uniform Assessment System) evaluation completed shows moderating impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, and transportation; maximal assistance with managing medications, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting; extensive assistance with equipment management, bed mobility and eating. DME (Durable Medical Equipment) includes a bedside commode, shower chair, and walker. She has bowel and bladder incontinence.  Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in managing finances, transportation, personal hygiene, locomotion, and toileting.  An appeal statement from New York State notes the member has several chronic medical conditions, needs to be promoted, and requires assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation.  States the member needs to be changed several times during day and night due to incontinence. Notes the member frequently wakes up during the night due to nocturnal cramps.  A letter from the member's daughter states she assists the member at night.  Notes the member wakes up around 1 am to get out of bed due to cramps.  This is relieved by the sitting position.  She assists with medications and other ADLs (activities of daily living).  An appeal letter from the provider states the member cannot be left alone due to falls while getting out of bed.  States he is legally blind.  Due to incontinence, he has skin breakdown with a Stage 1 decubitus sacral ulcer.  He requires frequent diaper changes and repositioning.

Yes. The proposed treatment is 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.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. The member has several chronic conditions including dementia and oxygen dependent COPD (chronic obstructive pulmonary disease).  The member lives alone.  He is no longer receiving informal support from his daughter. He is appealing denial of 24 hours per day, split shift - Personal Care Aide. The plan has approved 12 hour per day, 84 hours per week. The request was denied because lack of backup, living alone, and medical problems make the member medically unsafe in the Community. Per UAS (Uniform Assessment System) evaluation completed, the member requires assistance with all ADLS (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in managing finances, transportation, personal hygiene, locomotion, and toileting. The member is incontinent of bowel and bladder.  Appeal statements indicate that the member needs assistance during day and night, including assistance with transfers, repositioning, and diaper changes. This member has significant cognitive and physical impairments that have progressed between UAS (Uniform Assessment System) evaluations.  The documents provided support that the member needs assistance with ADLs during the night.  However, the documentation does not support that the frequency of care would prohibit the aide from getting five hours daily of uninterrupted sleep during the aide's shift.  The approved PCA (Personal Care Assistance) 84 hours per week is inadequate to meet the member's needs for assistance with ADLs/IADLs (activities of daily living/ Instrumental activities of daily living).  An increase in PCA to 24 hours per day, live in is medically necessary and appropriate to meets this member's needs.