Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, Parkinson's disease, chronic lymphocytic leukemia
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift)
The insurer denied Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift).
The denial is overturned.

This elderly male has medical conditions that include Alzheimer's dementia, Parkinson's disease, chronic lymphocytic leukemia, diabetic neuropathy, lower extremity atherosclerosis, asthma, chronic kidney disease, cataracts, and coronary artery disease. The denial of an increase in personal care aide (PCA) services for a total amount of 168 hours per week (split shift) is being appealed. The health plan approved 9 hours per day, 7 days per week, for a total of 63 hours per week. The Uniform Assessment System evaluation completed 2 months ago shows the patient has moderately impaired cognition and functional status and requires extensive assistance to total dependence with all activities of daily living. He has frequent bladder incontinence and infrequent bowel incontinence. Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with personal hygiene, toileting, bathing, 
walking, and locomotion. A statement notes there is a deterioration in the patient's short-term memory. He has had periods of extreme agitation over the past 90 days. He has incontinence and wakes up in the middle of the night for toileting, which prohibits an aide for getting four to five hours of uninterrupted sleep. He occasionally leaves the hours unsupervised. His physical mobility has worsened. He has imbalance and has had repeated falls. Letters from his Provider recommend an increase in hours for assistance with activities of daily living and due to the patient's poor insight.

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. This patient has multiple chronic conditions, including Alzheimer's dementia and Parkinson's disease. The denial of an increase in personal care aide (PCA) services for a total amount of 168 hours per week (split shift) is being appealed. The health plan approved nine hours per day, seven days per week, for a total of 63 hours per week. Uniform Assessment System (UAS) evaluation completed 2 months ago showed the patient requires extensive assistance to total dependence with all activities of daily living. The patient has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with personal hygiene, toileting, bathing, walking, and locomotion. Appeal statements report that both the patient's mental and physical conditions have deteriorated. Appeal statements support that the patient needs assistance with all activities of daily living, including frequent assistance at nighttime for toileting. The statements note the patient needs nighttime assistance that will not allow an aide to get four to five hours of uninterrupted sleep. The information provided supports that this patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved personal care aide 63 hours per week is insufficient to meet the patient's continuous needs. The proposed increase to 168 hours per week, split shift, is medically necessary.