Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD (chronic obstructive pulmonary disease), dementia, hypertension, incontinence, tremor, hypothyroidism, IBS (irritable bowel syndrome), Crohn's disuse, chronic kidney disease, respiratory failure, and chronic pain. 

Treatment: Personal Care Aide (PCA) Level II; 24 Hour Continuous Care, 7 Days Per Week. 

The insurer denied the Personal Care Aide (PCA) Level II; 24 Hour Continuous Care, 7 Days Per Week. 

The denial is overturned. 

The patient is a female. She has conditions including COPD (chronic obstructive pulmonary disease), dementia, hypertension, incontinence, tremor, hypothyroidism, IBS (irritable bowel syndrome), Crohn's disuse, chronic kidney disease, respiratory failure, and chronic pain. She lives alone. She is appealing denial of PCA (personal care aide) 24 hour continuous care, 7 days per week. She has been approved for an increase from PCA 70 hours per week to PCA 24 hour live-in, 7 days per week. 

UAS (Uniform Assessment System) evaluation completed shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, bathing, dressing, and toilet use; maximal assistance with managing medications, phone use, personal hygiene, and eating; and extensive assistance with walking, locomotion, bed mobility, toilet transfer, and bed mobility. She was hospitalized after presenting with encephalopathy secondary to Bactrim that was prescribed for a UTI (urinary tract infection). 

An appeal statement indicates the patient has progressive dementia. It notes the patient's son was providing informal support at night, but he is no longer able to do so. It further notes the patient needs assistance with ADLs (activities of daily living) as already accounted for in the UAS evaluation. It notes that the patient does not sleep through the night and her needs cannot be predicted. 

The patient uses a wheelchair for locomotion. She is frequently incontinent of bladder and occasionally incontinent of bowel. The patient's son reports that the patient gets up one to two times per night to use the bathroom. She has had falls in the last 90 days. An appeal statement from the provider notes the patient has unscheduled needs for assistance with changing diapers, transferring, positioning and other ADLs. Statements provided by the patient's son show the patient needing assistance with the bathroom and medications throughout the night. He notes that he is no longer able to provide informal support.

Yes, the Personal Care Aide (PCA) Level II; 24 Hour Continuous Care, 7 Days Per Week is medically necessary. 

The requested health service is consistent with generally accepted standards of medical practice. 

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services. 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 provider five hours daily of uninterrupted sleep during the aide's shift. Denial of the requested PCA continuous 24 hour per day is being appealed. She has been approved for PCA 24 hour live-in. 

This patient has multiple chronic conditions, including dementia. The patient was receiving informal support from her son, who is no longer able to provide this support. UAS evaluation completed shows the patient requires assistance with all ADLs/IADLs (instrumental activities of daily living). She is frequently incontinent of bladder. She has a history of falls in the last 90 days. Appeal information shows that the patient has needs for unscheduled assistance including nighttime toileting, changing diapers and medication administration. UAS evaluation and appeal letters show the patient needs assistance with ADLs throughout the day and night. Nighttime assistance is unscheduled. This patient has continuous needs that cannot be met with the approved PCA 24 hour per day, live-in. The proposed increase to PCA 24 hour per day, split shift is medically necessary to meet this patient's need for assistance with ADLs and personal care.