Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, back pain, diabetes, hypertension, acute kidney failure, multiple myeloma in remission, and unsteady gait. 
Treatment: Personal Care Assistance 24 Hours per Day, Seven Days per Week, a Total of 168 Hours per Week, Split Shifts. 

The insurer denied the Personal Care Assistance 24 Hours per Day, Seven Days per Week, a Total of 168 Hours per Week, Split Shifts. 

The denial is overturned. 

This patient is a female with conditions including dementia, back pain, diabetes, hypertension, acute kidney failure, multiple myeloma in remission, and unsteady gait.  She is appealing denial of Personal Care Assistance 24 hours per day, seven days per week, total of 168 hours per week, split shift. The patient's plan approval ended. Personal care aide (PCA) was denied based on the patient's need for skilled services and safety issues that cannot be met with a personal care aide (PCA) due to need for medication administration that exceed the personal care aide's scope. The patient is recommended to remain in a nursing home. 

The patient was admitted to the hospital due to wandering and confusion. Extended care facility reports note: The patient requires scheduled and as needed medication; she is able to ambulate with a rolling walker with close supervision; and she has forgetfulness and is not self-directing with care. Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: maximal assistance with meal preparation, housework, managing finances and medications, and shopping; extensive assistance with phone use, stairs, transportation, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion and toileting; independent with bed mobility;  and supervision with eating. The patient is incontinent of bowel and bladder. She does not have informal support.  A social worker notes the patient requires 24/7 care and cannot safely be let alone due to wandering and fear of leaving stove unattended. She was discharged to home. Uniform Assessment System (UAS) evaluation completed after admission shows decline in functional status to total dependence with housework, managing finances, and shopping; maximal assistance with phone use, bathing, personal hygiene, lower body dressing, and toilet use; and extensive assistance with upper body dressing, toilet transfer. 

Appeal statement notes the patient's medial condition has deteriorated since her hospitalization due to a fall.  It notes the patient needs assistance with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation.  It states the patient can be safely served with continuous personal care services (PCS).  A letter from Nurse Practitioner (NP) notes the patient has chronic debilitating conditions requiring 24 hours of home care.  Appeal letter from the provider states the patient needs assistance with activities of daily living (ADLs), including nighttime needs due to incontinence of bowel and bladder.  It states the patient needs repositioning every two hours.  It recommends 24 hours split shift care. 

Yes, the proposed treatment is medically necessary. 

Personal care services are 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 several chronic conditions including dementia. She was hospitalized after wandering. She was discharged from extended care previously. She is appealing denial of Personal Care Assistance 24 hours per day, seven days per week, total of 168 hours per week, split shift.  Per Uniform Assessment System (UAS) evaluation completed after admission, the patient requires assistance with all activities of daily living (ADLs), except eating. Compared to the Uniform Assessment System (UAS) evaluation completed previously there has been a decline in functional status to total dependence with housework, managing finances, and shopping; maximal assistance with phone use, bathing, personal hygiene, lower body dressing, and toilet use; and extensive assistance with upper body dressing, toilet transfer.  Appeal letters note the patient needs 24-hour care for assistance with activities of daily living (ADLs) and continuous supervision.  The most recent statement from one of the patient's providers notes the patient needs nighttime assistance due to incontinence as well as repositioning every two hours.  This patient has significant cognitive and physical impairments that have progressed between Uniform Assessment System (UAS) evaluations.  Based on her nighttime needs that include repositioning every two hours, the proposed Personal Care Assistance 24 hours per day, seven days per week, total of 168 hours per week, split shift is medically necessary to meet this patient's needs for assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs).