Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 

The insurer denied Personal Care Aide (PCA) Level 2: 16 hours per day-3 days per week; 12 hours per day-4 days per week; 12 hours per day-4 days per week; for a total of 144 hours per week. 
The denial is upheld. 

The patient is a female with progressive memory loss of Alzheimer's type, gait dysfunction, hearing disability and visual disability. The patient is requesting a personal care aide level 2, 16 hours a day times () 3 days a week, 12 hours a day split shift to 4 days a week for a total of 144 hours a week. Services were denied based upon medical necessity. Previously the plan approved 16 hours a day  5 days a week, 12 hours a day  2 split shift two days per week for a total of 128 hours a week and the patient is appealing the decision.
At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 16 hours per day-3 days per week; 12 hours per day-4 days per week; 12 hours per day-4 days per week; for a total of 144 hours per week.

The health plan's determination of medical necessity is upheld in whole.

The requested health service of Personal Care Aide (PCA) Level 2: 16 hours per day-3 days per week; 12 hours per day-4 days per week; 12 hours per day-4 days per week; for a total of 144 hours per week is not medically necessary for this patient.
Services were requested by the patient's daughter stating that the patient cannot be left alone at night and that the patient needs more assistance with walking, toileting, eating, in preparation and someone to talk to you. Services were denied by the patient's insurance stating the following, the patient is "able to walk with assistance with a walker." The patient is "incontinent in both bowel and bladder function which is being managed with your incontinent supplies." The patient is "able to feed yourself with some assistance once your meals are prepared by your caregiver. Time has been allotted for meal preparation." The patient requires "safety monitoring and supervision as a standalone task." The patent has "a walker, wheelchair, commode, shower chair and shower grab bar in your home to assist" with her needs. The services requested for nighttime with a split shift include mainly safety and supervision along with prevention of falls without any stand-alone specific activities of daily living (ADL)s or Instrumental activities of daily living (IADL)s being performed. Continent needs during these nocturnal hours have been provided for by an incontinent product.
The patient's memory loss is of concern, however, for services to be medically necessary, there must be a demonstrated need for ADLs or IADLs above and beyond observation and preventing falls. Specifically, the aide must be performing a service such as an ADL or IADL to be a covered service. Aide services for watching the patient in the middle of the night without performing a medically necessary ADL would be considered observation and typically not a service considered medically necessary. The documentation provided did not note specific needs for the additional 12 hours a day  5 days a week split shift. 
Therefore, the requested health service of Personal Care Aide (PCA) Level 2: 16 hours per day-3 days per week; 12 hours per day-4 days per week; 12 hours per day-4 days per week; for a total of 144 hours per week is not medically necessary.