Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Pain.
Treatment for personal care aide (PCA) services of 7 days per week, 2-12 hour split shifts.
The insurer denied coverage for personal care aide (PCA) services of 7 days per week, 2-12 hour split shifts.
The denial is overturned.

This is an elderly patient with extensive medical history associated with functional impairment and relies on caregivers for assistance with all daily activities. The patient lives alone and depends primarily on personal care aide (PCA) services for assistance with all activities of daily living (ADL) and instrumental activities of daily living (IADL). The UAS [uniform assessment system] identifies one informal helper (daughter) who provides some assistance (3 hours over 3 days including managing medications). The patient had been receiving PCA services (2)-12 hours split shifts. 

The patient is at high risk for skin injury. She has frequent incontinence and impaired bed mobility. The appealer noted that before split shift services, the patient's diaper was often full of urine and feces until the aide arrived; and the patient developed redness of the skin; most likely due to incontinence associated skin damage. In fact, the UAS nurse commented that the patient is at risk for diminished skin integrity due to incontinence. 

Regarding pressure ulcers, the patient is at high risk due to frequent incontinence and impaired bed mobility. The patient is unable to adequately reposition herself to relieve pressure on a regular basis. A pressure reducing mattress is helpful but does not eliminate the need for full pressure relief in high-risk locations such as sacrum, buttocks, heels. Pressure ulcers are a source of pain and associated with complications such as infection/sepsis and possible surgical intervention. The physician's letter indicated patient should be repositioned every 2 hours. When the patient is repositioned during incontinence care and/or for pain relief, these tasks may be done with sufficient frequency to also provide adequate pressure relief. However, if the patient does not need repositioning for other reasons after 2-3 hours, repositioning for pressure relief is indicated. 

The patient has chronic pain, including lower back pain, which can be exacerbated by lying in one position for an extended period of time. The patient relies on the aide as the only source of pain relief (e.g., repositioning from an uncomfortable position; assist with medication). Regarding pressure relief, the physician recommended repositioning every 2 hours. Repositioning for pain or during incontinence care can also serve the purpose of pressure relief; but when the aide is sleeping for 5 hours, then the patient will not have incontinence care, or repositioning for pain or pressure relief. It is not in the patient's best interest to remain in the same position for up to 5 hours, especially when she may also be lying in a soiled diaper. The fact that the patient's skin was intact at the time of the UAS should be a reason for continuing split shift services; not stopping it. 
                                                                                   
The frequency of the patient's daily care needs is not compatible with live-in aide services. During the day hours, the aide has all morning and evening ADLs; meal preparation for all meals, including service and assistance with eating; all housekeeping tasks plus all toileting/incontinence care and repositioning throughout the day as well as during the night. There does not appear to be a clear window of opportunity for a live-in aide to have 5 uninterrupted hours of sleep per day on a regular basis. 

Recommendation is given to reverse the decision to reduce Personal Care Aide services to 7 days per week, live-in; and to approve Personal Care Aide services 7 days per week (2) - 12 hours (split shifts). The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the requested Personal Care Aide (PCA) Services of 7 days per week, 2-12 hour split shifts is substantiated. The insurer's denial is overturned.