Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, pulmonary hypertension, back pain, and dementia
Treatment: Increase In Personal Care Assistant (PCA) Services From 7 Days x (times) 12 Hours To Continuous Care Split Shift
The insurer denied the increase in PCA services from 7 days x 12 hours to continuous care split shift.
The denial is upheld.

The patient is a female. Her conditions include coronary artery disease, pulmonary hypertension, back pain, and dementia. She has a history of a fall with left hip fracture. Denial of increase in personal care assistant (PCA) services from 7 days x (times) 12 hours to continuous care split shift, is being appealed. The health plan approved PCA services 7 days x 24 hours (live-in) per week.

Uniform Assessment System (UAS) evaluation completed approximately a year ago notes the patient has moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with transportation, bathing and dressing; extensive assistance with persona hygiene, walking, locomotion, toileting, and eating; and independent with bed mobility. She has frequent bowel and bladder incontinence. Compared to UAS evaluation completed most recently, there has been a decline in cognition and functional status of personal hygiene, upper body dressing, walking, locomotion, and bowel incontinence.

A letter from the patient's doctor notes the patient has advanced chronic condition and is dependent on home care services. She is a high risk for falls. She is mostly bed bound and at high risk for decubiti. A report from a provider notes the patient's condition has deteriorated. She is unable to ambulate on her own and uses a wheelchair. There is no significant change in her physical functioning.

No, the requested increase in PCA services to continuous care split shift is not medically necessary.

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

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. Denial of increase in PCA services from 7 days x 24 hours (live-in) per week to continuous care split shift is being appealed.

The patient has several chronic conditions. She had a fall that resulted in a hip fracture. UAS evaluation shows the patient needs assistance with all ADLs (activities of daily living). Compared to UAS evaluation completed most recently, there has been a decline in cognition and functional status of personal hygiene, upper body dressing, walking, locomotion, and bowel incontinence. The appeal statement from her doctor notes she has several chronic conditions, is mostly bed-bound and dependent on home care. She is at high risk for falls. This patient requires significant assistance with ADLs and personal care. However, the information provided does not support that the patient requires continuous care. She does not require frequent care, such as turning/repositioning that would prevent an aide from obtaining five hours daily of uninterrupted sleep during the aide's shift. The approved PCA 7 days x 24 hours (live-in) per week is sufficient to meet this patient's needs. The proposed increase to continuous care split shift is not medically necessary.