Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Increase in Personal Care Services (PCS) 24 hours a day, 5 days a week (split shift), for a total of 120 hours a week
The insurer denied the increase in PCS 24 hours a day, 5 days a week (split shift), for a total of 120 hours a week.
The denial is upheld.

This female has conditions including dementia, hypertension, glaucoma, atrial fibrillation, and disorder of sleep-wake cycle.  The daughter is appealing denial of increase in Personal Care Services (PCS) 24 hours a day, 5 days a week, split shift, total of 120 hours a week.  She has been approved for 8 hours a day, 5 days a week, total of 40 hours a week.  The daughter is requesting additional hours due to worsening memory and sometimes wandering.  UAS (Uniform Assessment System) evaluation completed shows the patient needs assistance with meal preparation, housekeeping, laundry, shopping, hygiene, dressing, moving around, toileting, and bathing.  She ambulates with a walker.  She has incontinence.  She lives with her family members.  Appeal letter from her provider notes the patient requires prompting and assistance with ADLs (activities of daily living).  She is incontinent and requires changing during day and overnight hours.  States she must be checked every four hours to maintain skin integrity.  She is a fall risk.  States she wakes up frequently at night and requires support and assistance.

No, the proposed treatment is not medically necessary.

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 personal care service 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.  The patient has multiple chronic conditions including dementia.  She lives with her family members.  The patient's daughter is appealing denial of increase in PCS 24 hours a day, 5 days a week, split shift, total of 120 hours a week.  She has been approved for 8 hours a day, 5 days a week, total of 40 hours a week.  UAS evaluation shows the patient needs assistance with meal preparation, housekeeping, laundry, shopping, hygiene, dressing, moving around, toileting, and bathing.  She has incontinence.  The daughter notes the patient has worsening memory and sometimes wanders.  Appeal statement from the provider notes the patient needs to be checked every 4 hours for incontinence.  States the patient wakes up frequently at night and needs support.  The information provided is inadequate to support the need for continuous needs.  The patient does not need frequent turning/repositioning.  The information shows that the patient needs supervision.  PCS is not indicated for supervision.  The approved PCS 40 hours a week is appropriate to meet this patient's needs with ADLs/IADLs (instrumental activities of daily living).  The proposed PCS 24 hours a day, 5 days a week, split shift, total of 120 hours a week is not medically necessary.