Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, Osteoarthritis, and Hypertension. 
Treatment: Personal Care Aide Level II: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (Split Shift); a total of 168 hours per week. 
The insurer denied: Personal Care Aide Level II: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (Split Shift); a total of 168 hours per week. 
The denial is upheld. 

This elderly female has conditions including dementia, osteoarthritis, and hypertension. She was hospitalized for a psychotic episode. She is appealing denial of personal care aide (PCA) 12 hours per day, seven days per week: 12 hours per day, seven days per week (split shift), for a total of 168 hours per week. The health plan approved personal care aide (PCA) 12 hours per day, seven days per week, for a total of 84 hours per week.
Uniform Assessment System (UAS) evaluation completed recently shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, phone use, bathing, lower body dressing, and toilet use; extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and bed mobility; and supervision with eating. She has bowel and bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation performed two months earlier, there has been a decline with lower body dressing, toilet use, bathing, eating, and bed mobility. 

The proposed treatment is not 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. 

This patient has multiple chronic conditions, including recent hospitalization for psychotic episode. She is appealing denial of personal care aide (PCA) 12 hours per day, seven days per week; 12 hours per day, seven days per week (split shift), for a total of 168 hours per week. The health plan approved personal care aide (PCA) 12 hours per day, seven days per week, for a total of 84 hours per week. Uniform Assessment System (UAS) evaluation completed on recently shows the patient needs assistance with all activities of daily living (ADLs), except eating. 

Compared to Uniform Assessment System (UAS) evaluation performed two months earlier, there has been a decline with lower body dressing, toilet use, bathing, eating, and bed mobility. The information provided does not support that the patient has continuous needs, such as transferring, turning, or positioning. Personal care aide (PCA) is not indicated for management of chronic medical conditions or for supervision. The increase in personal care aide (PCA) to 12 hours per day, seven days per week (split shift), for a total of 168 hours per week is not medically necessary. The patient's needs can be met with the approved personal care aide (PCA) 12 hours per day, seven days per week, for a total of 84 hours per week.