Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, hypertension, diabetes, degenerative joint disease, tremor, dizziness, weakness, and urinary incontinence.
Treatment: Increase Personal Care Aide (PCA) Services to A Split Shift For a Total of 168 Hours Per Week.
The insurer denied: Increase Personal Care Aide (PCA) Services to A Split Shift For a Total of 168 Hours Per Week.
The denial is overturned.

The patient is an elderly female. Her conditions include dementia, hypertension, diabetes, degenerative joint disease, tremor, dizziness, weakness, and urinary incontinence. Denial of increase personal care aide (PCA) services to a split shift for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week.
The patient's Uniform Assessment System (UAS) evaluation completed 6 months ago shows moderately impaired cognition and functional status of maximal assistance to total dependence with all ADLs (activities of daily living), except extensive assistance with eating. She has frequent bladder incontinence and occasional bowel incontinence. Appeal statements indicate the patient is homebound and must be wheeled by others. Her condition has weakened due to her recent pneumonia. She lives alone. Her provider notes that she needs 24-hour aide that would be unlikely to obtain five hours of daily uninterrupted sleep.
Night logs showed overnight assistance every 1 to 2 hours with toileting, transfers, and ambulation.

The requested Increase Personal Care Aide (PCA) Services to A Split Shift For a Total of 168 Hours Per Week 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. Denial of increase personal care aide (PCA) services to a split shift for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week.
This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed 6 months ago shows she requires maximal assistance to total dependence with all ADLs (activities of daily living), except extensive assistance with eating. She has bowel and bladder incontinence. The appeal statements support the patient is dependent with all ADLs (activities of daily living) and requires frequent assistance with toileting, transfers, and ambulation. Night logs show the patient needs overnight assistance every 1-2 hours. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved 
PCA (personal care aide) 84 hours per week is insufficient to meet this patient's needs for assistance. The requested PCA (personal care aide) split shift for a total of 168 hours per week is medically necessary.