Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day -7 days per week - (split-shift) for a total of 168 hours per week

The health plan denied: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day -7 days per week - (split-shift) for a total of 168 hours per week
The determination is: Overturned

The patient is a female with a medical history notable for dementia, incontinence, chronic kidney disease, and mobility issues. The patient is approved for 10.5 hours per day, 7 days per week (73.5 hours per week) of personal care assistance level 2 services. Her care team requested an increase to 24 hours per day (two-12-hour split shifts), 7 days per week (168 hours per week), and the request was denied by the health plan. The patient's physician provided a letter of support for this appeal. The letter states that the patient requires extensive and total assistance with all activities of daily living. She requires assistance with transfers, bathing, toileting, and repositioning in bed. The physician therefore asserts that the patient requires 24-hour continuous assistance. She lives with her husband who is of advanced age and had a stroke; he is no longer able to provide any informal support.
Personal caregiver logs were provided for review. These logs detail all of the personal care tasks that the patient requires overnight. The logs demonstrate that the patient requires repositioning to relieve pressure on her back, changing incontinence care products, and application of barrier cream, as well as cleaning after episodes of incontinence. These tasks occur with a frequency of every one to three hours overnight during the time period that the logs were completed.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient lives in a home with her husband. Her cognition was impaired. She was disoriented to time and place. Her recall was 0/3 at 5 minutes and she did not have any procedural memory. The patient speaks in nonsensical terms and is not able to direct her own care. She requires total dependence for essentially all instrumental activities of daily living and activities of daily living. She is completely incontinent of bowel and bladder, requiring the use of diapers and incontinence care pads. Compared to a prior assessment, she showed a decline in cognitive and functional status.
At issue is the medical necessity of Personal Care Aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week - (split-shift) for a total of 168 hours per week.
The health plan's determination of medical necessity is overturned in whole.
The requested health service of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - (split-shift) for a total of 168 hours per week is medically necessary for this patient.
The patient has severe limitations in her ability to care for herself secondary to dementia and other medical problems. She requires total dependence for essentially all activities of daily living. The nighttime care logs demonstrate that she requires care continuously throughout the night, which is consistent with her incontinence and dementia. The documentation states that she has been receiving informal support from her family to fill in these care gaps, but her family is no longer able to provide this support. Therefore, it is medically necessary and reasonable to provide continuous personal care assistance via 24-hour split shift care. Given that her personal care needs are expected to occur with a frequency of every one to three hours overnight, a 24-hour live-in personal care aid would not be appropriate. The documentation supports the medical necessity for a continuous split shift personal care aide.