Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, neuropathy, hypertension, obesity, and lung disease. 
Treatment: Personal Care Assistance Services 24 hours, 2-12 hours split shift. 

The insurer denied the Personal Care Assistance Services 24 hours, 2-12 hours split shift. 
The denial is overturned. 

The patient is a female. Her conditions include Parkinson's disease, neuropathy, hypertension, obesity, and lung disease. Denial of personal care assistance (PCA) services 24 hours, 2-12 hours split shift, is being appealed. The plan approved PCA (personal care assistance) services 12 hours per day 7 days per week, a total of 84 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, managing finances and medications, shopping, bathing, lower body dressing, and toilet use; and extensive assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, bed mobility and eating.  She has frequent bladder incontinence.  UAS (Uniform Assessment System) evaluation completed most recently shows progression to moderately impaired cognition and total dependence with meal preparation, housework, managing finances, bathing, personal hygiene, dressing, bed mobility and eating. 

A letter from the patient's provider notes the patient has progressive weakness.  The patient has difficulty with ADLs (activities of daily living) and self-care.  She is at risk for falling, skin breakdown and harm.  A letter from another provider notes the patient needs 2-12 hour shifts, including night time hours for close attention to pain and cramping.  Clinical records show the patient needs nighttime help with turning, repositioning, transferring, management of incontinence, and assistance with pain and cramping. 

Yes, the requested Personal Care Assistance Services 24 hours, 2-12 hours split shift 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 PCA (personal care assistance) services 24 hours, 2-12 hours split shift, is being appealed. The plan approved PCA (personal care assistance) services 12 hours per day 7 days per week, a total of 84 hours per week. 

This patient has multiple chronic progressive medical conditions. UAS (uniform assessment system) evaluation completed most recently, shows the patient requires maximal assistance to total dependence with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a deterioration in the patient's functioning. Appeal letters note that the patient has progressive conditions and needs assistance during day and night time. Records show that she needs assistance to include turning, repositioning, transferring, and management of incontinence. This patient has significant limitations in ability to perform ADLs (activities of daily living) and personal care. The information provided supports the requested PCA (personal care assistance) services 24 hours, 2-12 hours split shift to assist needs as noted above. Based on her needs, it is unlikely that a live-in aide would get five hours daily of uninterrupted sleep. 

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