Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Aide (PCA) services: 2-12 hour split shifts, 7 days a week (Health Plan has approved PCA services live-in 7 days a week). 

The insurer denied: Personal Care Aide services: 2-12-hour split shifts, 7 days a week (Health Plan has approved PCA services live-in 7 days a week). 
The denial is overturned. 

This elderly male has conditions including dementia, osteomyelitis. He is appealing denial of personal care aide services at 12 hour split shifts, 7 days a week. The health plan has approved PCA (personal care aide) services live-in 7 days a week. Uniform Assessment System (UAS) evaluation completed on recently shows severely impaired cognition and function status: total dependence with housework, meal preparation, managing finances, shopping bathing, and lower body dressing; maximal assistance with managing medications, personal hygiene, upper body dressing, walking, locomotion, and toileting; and extensive assistance with bed mobility and eating. He has bladder incontinence. A letter from the Provider notes the member has progressive dementia and orthostatic hypotension, which requires 24/7 supervision. 

He is at risk of fall and needs assistance with ADLs (activities of daily living). A progress note states the member is on IV (intravenous) antibiotics for osteomyelitis as a complication of a fall. Has been getting up through the night, which increases risk for falling. A letter from another Provider notes the member needs assistance with ADLs (activities of daily living), including overnight toileting needs. He is debilitated and at high risk for falls. There are logs showing the member receiving assistance every 1-2 hours during the night with ADLs (activities of daily living) and toileting. 

The proposed treatment 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. He is appealing denial of personal care aide services at 12 hour split shifts, 7 days a week. The health plan has approved PCA (personal care aide) services live-in 7 days a week. The plan denied the requested services based on the assessment of functional and medical status. The Uniform Assessment System (UAS) evaluation completed recently shows the member requires extensive assistance total dependence with all ADLs (activities of daily living). He has bladder incontinence. Appeal statements show the member is debilitated and has progressive of dementia. They support the member needs assistance with all ADLs (activities of daily living), including overnight. Personal care logs have been provided showing the member receiving assistance every 1-2 hour with ADLs (activities of daily living).and toileting. This member 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) services live-in 7 days a week is insufficient to meet the member's needs for assistance with ADLs (activities of daily living). and personal care. The proposed PCA (personal care aide) 12 hour split shifts, 7 days a week is medically necessary.