Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legal blindness, hypertension, chronic obstructive pulmonary disease, urinary incontinence, irritable bowel syndrome, osteoarthritis, and anxiety. 
Treatment: Personal Care Aide Level 2 12 Hours x 2x7 Days (split shift) A Total of 168 Hours /Week. 

The insurer denied the Personal Care Aide Level 2 12 Hours x 2x7 Days (split shift) A Total of 168 Hours /Week. 
The denial is overturned. 

The patient is a female. Her conditions include legal blindness, hypertension, chronic obstructive pulmonary disease, urinary incontinence, irritable bowel syndrome, osteoarthritis, and anxiety. Denial of personal care aide (PCA) 12 hours x 2 x 7 days, split shift, for a total of 168 hours per week, is being appealed. The plan approved 84 hours per week 12 hours per day x 7 days per week. 

Uniform Assessment Systems (UAS) evaluation performed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, stairs, shopping, transportation, bathing, dressing, walking, locomotion, and toileting; extensive assistance with managing finances and medications, and personal hygiene; and limited assisted with bed mobility and eating. She has frequent bladder incontinence and infrequent bowel incontinence. 

An appeal letter from the patient's son notes that the patient had a fall that resulting in a thoracic compression fracture. After discharge, she had to be carried upstairs by two paramedics. Her motion is limited due to need to wear and lumbosacral back brace. She need to be tuned every two hours. It is noted she requires total assistance with all ADLs (activities of daily living) throughout the day and night. 

Letters from providers have been submitted for review. A letter from one provider notes the patient requires toileting every two hours and more frequently through the night due to overactive bladder. She requires diaper change every two hours. 

Yes, the requested Personal Care Aide 168 hours/week, 24 hours/day, split shift, is medically necessary. 

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

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 Aide) 12 hours x 2 x 7 days, split shift, for a total of 168 hours per week, is being appealed. The plan approved 84 hours per week 12 hours per day x 7 days per week. 

The patient has several chronic conditions, including recent thoracic compression fracture after a fall. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). She has frequent bladder incontinence and infrequent bowel incontinence. Appeal letters from providers note the patient has several chronic conditions and needs constant care. The patient needs frequent assistance with toileting due to overactive bladder to include diaper change every 2 hours. The patient's son notes she needs to be turned every 2 hours. She has physical limitations due to lumbosacral brace. This patient has significant physical impairments that affect mobility and results in need for assistance with all ADLs (activities of daily living), including frequent assistance with toileting and turning. This frequency of assistance is unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved PCA (personal care aide) 84 hours per week is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living)/IADLs (instrumental activities of daily living). The proposed increase in PCA (personal care aide) to 12 hours x 2 x 7 days, split shift, for a total of 168 hours per week medically necessary.