Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Quadriplegia, Chiari malformation, neurogenic bladder and bowel, Ehlers-Danlos syndrome, psoriatic arthritis, dysautonomia, and sleep apnea
Treatment: Personal Care Assistance Services (PCAS) 24 hours/day, 7 days/week (split shift) for a total of 168 hours/week
The insurer denied PCAS 24 hours/day, 7 days/week (split shift) for a total of 168 hours/week.
The denial is upheld.

The patient is an adult male. His conditions include quadriplegia, Chiari malformation, neurogenic bladder and bowel, Ehlers-Danlos syndrome, psoriatic arthritis, dysautonomia, and sleep apnea. Denial of personal care assistance services (PCAS) 24 hours/day, 7 days/week (split shift) for a total of 168 hours/week, is being appealed. The health plan approved personal care assistance (PCA) for 65 hours/week and consumer directed personal assistance service (CDPAS) for 36 hours/week.
The patient's Uniform Assessment System (UAS) evaluation completed approximately 6 months ago shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, lower body dressing, and toileting; extensive assistance with managing medications, personal hygiene, upper body dressing, and bed mobility; and limited assistance with managing finances, phone use, locomotion, and eating. He uses urinary catheter every four hours. A letter from the patient's provider notes the patient needs assistance with ADLs (activities of daily living). He has worsening bowel and bladder incontinence. A letter from another provider notes the patient is dependent with ADLs. He has worsened debility. He is unable to meet hygienic needs and is at risk or urinary tract infections and skin breakdown. He requires help with ADLs and repositioning at night. A letter from another provider notes the patient has nighttime incontinence and needs overnight help. He has recurrent urinary tract infections.  

The requested PCAS 24 hours/day, 7 days/week (split shift) for a total of 168 hours/week is not medically necessary. 

Personal care service (PCS) 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 PCS 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 PCAS 24 hours/day, 7 days/week (split shift) for a total of 168 hours/week, is being appealed. The health plan approved PCA for 65 hours/week and CDPAS for 36 hours/week.

This patient has multiple medical conditions, including quadriplegia with neurogenic bladder and bowel. UAS evaluation completed approximately six months ago shows he requires assistance with all ADLs. He uses urinary catheter every 4 hours. Appeal statements note the patient has worsening bowel and bladder incontinence and recurrent urinary tract infections. The information does not support that the patient has continuous needs. The information does not support the need for additional hours that cannot be met with the approved PCA for 65 hours/week and CDPAS for 36 hours/week. The requested PCAS 24 hours/day, 7 days/week (split shift) for a total of 168 hours/week is not medically necessary.