Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular dementia.
Treatment:  Increase Personal Care Aide Service 7 Days x (2)12 Hours (Split Shift)
The insurer denied the  Increase Personal Care Aide Service 7 Days x (2)12 Hours (Split Shift).
The denial is overturned. 

This patient is a male with vascular dementia.  This is an appeal for personal care aide (PCA) seven days, 12 hours, split shift.  The patient was approved for seven days x 24 hours. 

An assessment performed shows severely impaired cognition and function status:  total dependence with meal preparation, housework, managing finances, bathing, personal hygiene, dressing, and eating; and maximal assistance with managing medications, bed mobility.  The patient is turned/repositioned every two hours.  Due to bowel/bladder incontinence, he requires diaper changes ten times per day.  Compared to previous assessment performed, there has been a significant decline in the patient's functional status.  The patient lives alone and is nonverbal.  He has declined since the death of his spouse.  An appeal letter from the patient's provider states the patient has extreme and rapid deterioration in cognition and physical health. The provider states the patient is immobile and confined to bed where he is unable to move or position himself. The patient is completely dependent on others, the patient has several chronic medical conditions, including debilitating pain due to osteoarthritis (OA), impaired vision, poor stamina, hearing loss, vertigo, and urinary and fecal incontinence.  The provider states the patient requires 24/7 assistance including bi-hourly turning/position.

Yes, the proposed treatment is medically necessary.

Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, and the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

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 provider five hours daily of uninterrupted sleep during the aide's shift. 

This patient has multiple chronic conditions, including dementia, that have progressed since the death of his spouse.  Per the provider, the patient is bedbound.  This patient requires assistance with all activities of daily living (ADLs) and personal care needs.  Assessment performed showed significant deterioration in functional status compared to previous assessment performed.  The patient requires maximal assistance to total dependence with all activities of daily living / instrumental activities of daily living. He requires bihourly turning/repositioning and frequent diaper changes.  This patient has continuous needs that cannot be met with a 24-hour personal care aide (PCA) because given the frequency of care it be unlikely for the assistant to get five hours daily of uninterrupted sleep during the aide's shift.  Based on the progression of this patient's condition, the proposed increase to personal care aide (PCA) seven days x (2)12 hours (split shift) is medically necessary to meet this patient's needs for assistance as noted above.