Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems/Coronary Artery Disease/CAD
Home health Care/PCA 2 12-hour split shift, 7 days per week
The health plan denied the requested PCA 2 12-hour split shift, 7 days per week as not medically necessary. The health plan's determination is overturned.

This is a case review for a female with a medical history notable for coronary artery disease, dizziness, dementia, and urinary incontinence. The patient is approved for personal care assistant services (PCA) 7 days per week of live-in personal care assistance. The patient and her care team requested an increase to 24 hours per day (2-12-hour split-shift), 7 days per week.
The patient's physician provided a letter of support for this appeal. The letter states that the patient's condition has significantly deteriorated. She requires assistance with personal care including incontinence care. She is unable to reposition herself in bed and the physician requests turning and repositioning every 2 hours during the day and night. He also requests that she receive prompt assistance with incontinence care to prevent skin breakdown.
The patient's daughter provided a letter of support for this appeal. The letter describes the patient as "bed bound...unable to walk, sit, or move in bed." She is incontinent of stool and urine, and unable to manage her own incontinence care. She requires assistance with repositioning in bed.
A community advocate provided a letter of support for this appeal. The letter outlines several of the concerns and recommendations of the physician and the patient's daughter as detailed above.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient was alert and oriented times two only; she was forgetful and unable to describe procedural tasks. She is able to make some needs and wants understood. For her instrumental activities of daily living, she requires total dependence for meal preparation, housework, finances, stairs, and transportation. She requires maximal assistance for medications, phone use, and shopping. For her activities of daily living, she requires total dependence for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires maximal assistance for hygiene, dressing upper body, and bed mobility. She requires extensive assistance for eating. She is frequently incontinent of urine and stool.
Letters from home physical therapy were provided for review. She was discharged from physical therapy. At that time, she was able to perform some transfers without assistance but still required "verbal cue for safe toilet transfer."
At issue is the medical necessity for the requested health service/treatment of PCA 2-12-hour split shift, 7 days per week.

The health plan's determination of medical necessity is overturned, in whole.

The requested health service of PCA 2 12-hour split shift, 7 days per week is medically necessary for this patient.
The patient's physician and family have attested that she is unable to transfer without assistance, and this was supported by the findings in the UAS. The patient has dementia and incontinence. She requires overnight care including turning and repositioning in bed, and she requires maximal assistance for bed mobility. She is not able to direct her own care and will need assistance with unscheduled overnight episodes of incontinence. Because her personal care needs are expected to be continuous throughout the night, live-in personal care aides would not be able to get the required uninterrupted rest periods overnight. Therefore, split-shift 24-hour care is medically necessary for the patient.