Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, diabetes mellitus, depression and coronary heart disease

Treatment: Personal Care Aide: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week

The insurer denied coverage for increase in Personal Care Aide: split shift - total of 168 hours per week

The denial is overturned

This elderly patient has substantial physical and cognitive impairment associated with several medical conditions and depends on caregivers for help with all activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). He lives alone. His daughter is the only informal caregiver identified in the recent Uniform Assessment System (UAS). Her ability to help the patient is limited due to her own health issues; she provides some assistance with IADLs. The patient relies primarily on personal care aide (PCA) services for assistance with daily activities. He has been receiving PCA live-in services. The daughter reported the patient's health has declined and his mental status changed. Increase of PCA services was requested (via patient designee) for PCA two 12-hour shifts per day (split shift), 168 hours per week. 

The most recent UAS was reviewed, and the functional status report indicates the patient is totally dependent for all IADLs. For ADLs, the patient is totally dependent for bathing, personal hygiene, dressing upper/lower body, locomotion, toilet use; he needs maximal assistance for walking, transfer toilet, bed mobility, eating. 

It is reported the patient has behavioral problems associated with dementia. The UAS and physician's letter indicate the patient has episodes of agitation, screaming, resisting care; at times physically aggressive (shoves the caregiver); sundowning, confusion; delusions, hallucinations; and difficulty sleeping. One incident was described as patient shaking the bed siderail, causing it to break. 

The patient has chronic pain. The UAS indicates patient has osteoarthritis. It is noted that he has pain and stiffness in his back (causing difficulty bending); and in his shoulders (unable to elevate arms above shoulder level). These restrictions affect most ADLs, including lower body bathing and dressing (back pain); upper body dressing, bathing, personal hygiene, cleaning after toilet use (shoulder pain/stiffness). The patient has pain and weakness in his hands. As per UAS, the patient needs food utensils placed into his hand, and aide lifts patient's hand to assist with feeding. Hand pain and weakness limits activities that require hand function. Hand and shoulder pain can limit proper use of a walker due to poor hand grip and limited weight-bearing on the walker. The recent UAS reports patient needs maximal assistance for toilet transfer and is totally dependent for toilet use. 

Live-in services do not appear to meet the daily needs of the patient; and so continuous personal care services (split shift) are indicated.
 
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for increase in Personal Care Aide: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week is substantiated.