Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal fracture
Treatment: Increase Personal Care Aide (PCA) Services From 56 Hours/Week TO Seven Days/Week, 24 Hours/Day (split shift)
The insurer denied the Increase Personal Care Aide (PCA) Services From 56 Hours/Week TO Seven Days/Week, 24 Hours/Day (split shift)
The denial is upheld

The patient is a female. She is status post spinal fracture and has multiple hospitalizations; the most recent hospitalization due to urinary tract infection (UTI).   The denial of an increase in Personal Care Aide (PCA) services from 56 hours/week to seven days/week to 24 hours/day, split shift is being appealed. The request was denied by the health plan due to extent of assistance needed showed the patient was not safe for discharge back into the community.

UAS (Uniform Assessment System) evaluation completed showed the patient needed maximal to total assistance to perform activities of daily living, which has not significantly changed from previous ability.  She lives with her husband who has medical problems and recent surgery. Clinical notes show the patient is wheelchair-dependent and requires two person assistance with bed mobility, transfers, toileting, and locomotion. She has an indwelling Foley and frequent bowel incontinence.

The appeal statement notes the patient has improved with transfer and now requires two person extensive assist as opposed to a Hoyer. The appeal notes the patient has family support of spouse and three grandchildren.

No, the proposed increase in personal care services 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.  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.

This patient has multiple chronic conditions and is wheelchair bound.  She is appealing denial of increase Personal Care Aide (PCA) services from 56 hours/week to seven days/week to 24 hours/day, split shift.  Uniform Assessment System evaluation completed shows the patient requires maximal to total assistance with ADLs.  She has a Foley and bowel incontinence.  The patient requires two person assistance with bed mobility, transfers, toileting, and locomotion.  She is not able to take shower or bed bath given by personal care aide due to spinal fracture.  This evaluation shows no significant change from previous evaluation.  The patient lives with her husband who has medical problems.  She is noted to have grandchildren that can help.  This patient requires extensive assistance with activities of daily living including two person assistance with mobility and transfers.  There has been no significant improvement since the prior denial.  The documentation is inadequate to support that the patient has adequate informal support to meet the degree of needs with activities of daily living and personal care.  Personal Care aide (PCA) services are not indicated for safety supervision.  The information provided shows that it would be unsafe for the patient to live in the community.  A higher level of care is indicated.  Therefore, the requested increase personal care aide services from 56 hours/week to seven days/week to 24 hours/day, split shift is not medically necessary.