Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, COPD (chronic obstructive pulmonary disease), and glaucoma.
Treatment:  Personal Care Assistance, a total of 7 days per week, 24 hours per day (split shift) (TEMPORARY).

The insurer denied the Personal Care Assistance, a total of 7 days per week, 24 hours per day (split shift) (TEMPORARY).  The denial is overturned.

The patient is a female. She has medical conditions including dementia, COPD (chronic obstructive pulmonary disease), and glaucoma. She lives with her husband. Denial of temporary personal care assistance (PCA), a total of 7 days per week, 24 hours per day, split shift, is being appealed, because the plan is unable to staff with a Spanish speaking attendant. She is currently approved for 24 hours per day, live-in.

The patient's Uniform Assessment System (UAS) evaluation completed shows the patient has moderately impaired cognition and functional status requires assistance with all ADLs (activities of daily living). She is wheelchair bound. She is unable to ambulate and reposition herself. She is frequently incontinent of bowel and bladder.

An appeal statement notes the patient has multiple conditions. She does not have informal support. A Spanish speaking home attendant cannot be found to provide 14 hour live-in care. Notes the patient's health has deteriorated since hospitalization. She now requires full assistance with ADLs (activities of daily living) and transferring.

A letter notes the patient was recently hospitalized after a fall and left arm fracture. This was followed by two weeks of rehab. The letter states the patient has a functional decline and de-conditioned since returning home. She requires full assistance with all activities of daily living. She has a history of recurring incontinence with skin breakdown and requires assistance with toileting prior to bedtime and during the night. The family is requesting 12-hour split shift care.

A letter from the patient's doctor notes the patient is dependent on all ADLs (activities of daily living) and can benefit from 24-hour care. A letter from another doctor notes the patient has multiple conditions. Her husband is no longer able to provide assistance. Recommend 7 x 24 care.

A letter notes the home care agency is unable to provide a live-in Spanish-speaking attendant and is requesting temporary increase to 24-hour, split shift.

Yes, the requested Personal Care Assistance, a total of 7 days per week, 24 hours per day (split shift) (TEMPORARY) is medically necessary.

Personal care service is 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. Denial of temporary PCA (personal care assistance), a total of 7 days per week, 24 hours per day, split shift, is being appealed. She is currently approved for 24 hours per day, live-in. A temporary increase in hours has been requested because the Plan is unable to provide live-in staff with a Spanish-speaking attendant.

The patient has several chronic conditions, include a recent hospitalization after a fall. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). She has bowel and bladder incontinence. Appeal statements note that the patient's functional status has deteriorated since her hospitalization and now require assistance with all ADLs (activities of daily living). She is wheelchair bound and requires assistance with transfers and incontinence care. This patient is de-conditioned and has significant physical impairment. The Plan is unable to meet the patient's needs with a live-in Spanish-speaking attendant. The proposed temporary increase in PCA (personal care assistance) to a total of 7 days per week, 24 hours per day, split shift, is medically necessary and appropriate to meets this patient's needs with ADLs (activities of daily living) and personal care until the Plan is able to staff provide the live-in Spanish-speaking staff.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.