Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Personal Care Aide (PCA) Services For 
A Total of 168 Hours Per Week; 12 hours per day 7 days per week; 12 hours per day 7 days per week; split shift.
The insurer denied: Increase Personal Care Aide (PCA) Services For A Total of 168 Hours Per Week; 12 hours per day 7 days per week; 12 hours per day 7 days per week; split shift.
The denial is overturned.

The patient is an elderly female. She has dementia and is terminally ill. Denial of increase personal care aide (PCA) services for a total of 168 hours per week; 12 hours per day 7 days per week; 12 hours per day 7 days per week; split shift, is being appealed. The health plan approved 12 hours per day, 7 days per week, for a total of 84 hours per week.
Uniform Assessment System evaluation completed 6 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, shopping, and bathing; maximal assistance with phone use, dressing, toileting, walking, locomotion, and toileting; extensive assistance with bed mobility; and independent with personal hygiene and eating. She has bowel and bladder incontinence. A letter from the patient's provider notes the patient has severe dementia and is in hospice care. She needs 24-hour bedside care. A letter from the patient's provider notes the patient is bedbound and lives alone. She has a prognosis of less than six months. She has a pressure wound on her sacrum and needs repositioning every two hours. Daily logs are remarkable for nighttime turning every two to three hours.

The requested health service 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. Denial of increase personal care aide (PCA) services for a total of 168 hours per week; 12 hours per day 7 days per week; 12 hours per day 7 days per week; split shift, is being appealed. The health plan approved 12 hours per day, 7 days per week, for a total of 84 hours per week.
This patient is terminally ill and is bedbound. The health plan noted that granting additional hours are not provided when tasks are not being performed and for safety monitoring and supervision. 
Uniform Assessment System evaluation completed 6 months ago shows the patient requires assistance with all ADLs (activities of daily living), except personal hygiene and eating. She is incontinent of bowel and bladder. She has a sacral pressure ulcer and requires assistance with turning/repositioning. Frequent turning/repositioning is supported by nighttime logs. This patient has continuous needs, including frequent turning/repositioning that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved PCA (personal care aide) 84 hours per week is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The requested PCA (personal care aide) 168 hours per week; 12 hours per day 7 days per week; 12 hours per day 7 days per week; split shift, is medically necessary.