Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. Increase in services from 12 hours x 7 days (84 hours per week) of personal care assistant (PCA) services to continuous care split shift services (12 hours x 7 days of PCA services in combination with 80 hours per week of Consumer Directed Personal Assistant Services [CDPAS]). 
The insurer denied of increase in services from 12 hours x 7 days (84 hours per week) of personal care assistant (PCA) services to continuous care split shift services (12 hours x 7 days of PCA services in combination with 80 hours per week of Consumer Directed Personal Assistant Services [CDPAS]). 
The denial is overturned.

The patient is a female with past medical history of dementia, depression, frequent urinary incontinence, infrequent bowel incontinence, hypertension, gastroesophageal reflux disease (GERD), osteoporosis, and hyperlipidemia who underwent assessment virtually assessing the patient at total assistance with tasks of managing finances, managing medication, stairs, shopping, and transportation while maximum assistance with tasks of phone use, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. With tasks of personal hygiene, dressing upper body, and eating the patient was assessed at extensive assistance while limited assistance with task of bed mobility. Notes from the assessment stated the patient lived with her daughter, and daughter requested 80 hours a week of Consumer Directed Personal Assistance Program (CDPAP) services and Personal Care Aide (PCA) services 12 x 7 split shift. The notes also stated the patient had moderately impaired cognitive skills for daily decision making, was more confused at night due to episodes of sundowning but did not have agitation, resistance of care, or wandering and required a diaper change at 10 PM, 1 AM, and 6 AM. The patient was approved for CDPAP services, 24 hours/day, live-in but the family was unable to provide daytime coverage.

The patient has documented needs for assistance with tasks of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) as documented by the assessment, however, the patient does have continuous 24-hour care needs and a task based assessment should have been utilized to calculate hours of services needed. The patient had been approved for CDPAP services 24 hours/day, live-in, but the family was unable to secure an aide for all approved hours, therefore the family requested to continue PCA services 12 hours/day, 7 days/week with additional CDPAP services 80 hours/week. The patient's dementia causes her to be awake at night and during her time of awakeness requires assistance with ADL tasks of walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The plan stated that toileting needs alone do not constitute a reason for 24-hour services. The patient has unpredictable and unscheduled care needs that span a continuum of time and the health plan failed to document a plan to meet these unpredictable and unscheduled care needs. At the universal assessment, the daughter specifically noted the patient required toileting help 10 PM, 1 AM, and 6 AM which would not allow an aide 5 hours of uninterrupted sleep in the overnight hours. The requested increase in PCA/CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, continues care split shift services (12 hours/day X 7 days/week of PCA services in combination with 80 hours per week of CDPAP services) are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.