Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: PCA Level 2 12 hours per day, 7 days a week; 12 hours per day, 7 days a week (split-shift) total 168 hours per week
The insurer denied PCA Level 2 12 hours per day, 7 days a week; 12 hours per day, 7 days a week (split-shift) total 168 hours per week.
The determination is upheld.

This is a female patient with a history of dementia with significant memory loss and behavioral disturbances, history of multiple strokes, repeat falls, hypertension, aortic valve stenosis, chronic kidney disease stage 3, asthma, osteoarthritis, migraines, major depressive disorder with anxiety, insomnia, hand tremors, and vestibulopathy. She was hospitalized for altered mental status. She has been living at a nursing home and has been receiving physical therapy (PT) and occupational therapy (OT). An in-person Uniform Assessment System (UAS) was completed that states the patient lives alone in an apartment on the second floor in a building with an elevator and wheelchair access. Per the UAS, the patient's son prepours medications and provides reminders and the patient can take them. 
The patient's neurologist provided a letter of support. Her neurologist states that she has had multiple falls when left alone overnight, resulting in injuries, and that she is able to ambulate with a walker. He states that she is unable to take her medications correctly and has forgotten to turn off her gas stove in the past and burned several pots. 
A video UAS was completed and showed no significant changes in the patient's personal care needs as compared to the prior assessment. The only significant change was a change in cognition. 
The plan approved PCA Level 2 care for 6.5 hours per day, 7 days per week. The denial letter states that she has a shower chair, shower grab bar, and incontinence supplies. She also has a Personal Emergency Response System.
The patient's nursing home attending physician provided a letter of support for an appeal. He states that she is having worsening confusion throughout the day and night and impaired safety awareness and that she has a high risk of falls due to unsteady gait. At issue is the medical necessity of PCA Level 2 12 hours per day, 7 days a week; 12 hours per day, 7 days a week (split-shift) total 168 hours per week
Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested PCA Level 2 services 12 hours per day, 7 days a week (split-shift) for total 168 hours per week is not medically necessary.
Split-shift care requires proof that a PCA would be unable to receive 5 hours of uninterrupted rest. While the patient requires hands-on assistance for many activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) and while the patient's attending physician states that it is unlikely a PCA would be able to have 5 hours of uninterrupted rest, there is no documentation showing that patient currently requires frequent care overnight. There are no night-logs of care required overnight and no physician orders for frequent repositioning. Therefore, there is insufficient evidence of medical necessity for the requested increase in PCA hours. Additional hours are not provided when tasks are not being performed and for safety monitoring and supervision only.