Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, depression and coronary heart disease.
Treatment: Increase Personal Care Assistant (PCA) Services From 7 Day x 12 Hours Per Week To 7 Days x 24 Hours (continuous services) Per Week.

The insurer denied the Increase Personal Care Assistant (PCA) Services From 7 Day x 12 Hours Per Week To 7 Days x 24 Hours (continuous services) Per Week.

The denial is overturned. 

The patient is a male. His conditions include Alzheimer's dementia, depression and coronary heart disease. He lives alone in a one bedroom apartment. This is an appeal for denial of PCA (personal care assistant) services 24 hours, split shift. He has been approved for 24 hours live-in PCA (personal care assistant) services.

UAS (Uniform Assessment System) evaluation performed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, stairs, and shopping; maximal assistance with phone use, transportation, and bathing; extensive assistance with managing medications, dressing walking, locomotion, toileting, and bed mobility; limited assistance with personal hygiene and eating. The patient's activity level is less than one hour. He is frequently incontinent of bladder. He ambulates with a rolling walker. Compared to UAS (Uniform Assessment System) evaluation performed two months prior, there has been a decline in the patient's cognition, managing finances, transportation, bathing, bed mobility and eating. Activity level was three to four hours. UAS (Uniform Assessment System) encounter notes show deterioration in the patient's functional status. The progress report notes the patient is nonambulatory. Report notes the patient requested an increase in PCA (personal care assistant) hours. The patient's son states that the patient is unable to ambulate to the bathroom. The patient is frequently incontinent, and he is turned and repositioned every two hours. Progress report notes the patient's son states that he provides services at nighttime and declined live-in services. The patient's son declined PCA (personal care assistant) live-in services. Services were voluntarily kept at 84 hours per week. The provider has requested 24 hours continuous services.

Yes, the Increase Personal Care Assistant (PCA) Services From 7 Day x 12 Hours Per Week To 7 Days x 24 Hours (continuous services) Per Week is medically necessary.
Medically necessary services are those which are:
- safe 
- effective
- generally accepted national standard of medical practice 
- not provided primarily for convenience of the patient or the practitioner 
- the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested health service is medically necessary, because it is consistent with generally accepted national standards of medical practice.

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 provider five hours daily of uninterrupted sleep during the aide's shift. This is an appeal for denial of PCA (personal care assistant) services 24 hours, split shift. He has been approved for PCA (personal care assistant) services 24 hours, live-in.

This patient has multiple chronic conditions, including Alzheimer's dementia. UAS (Uniform Assessment System) evaluation performed shows the patient requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living). This evaluation shows significant decline in cognitive and functional status compared to UAS (Uniform Assessment System) evaluation performed two months prior. His activity level has declined from three to four to less than one hour. UAS (Uniform Assessment System) progress reports document deterioration in the patient's functional status to becoming non-ambulatory. The patient has become frequently incontinent and requires turning/repositioning every two hours. This patient has continuous needs that cannot be met with the approved PCA (personal care assistant) services 24 hours, live-in. The proposed increase in PCA (personal care assistant) services to 24 hours per day, split shift is medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.