Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular Disorder
Home Health Care

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) Services: Split Shift, 24 Hours per Day, 7 Days per Week
The insurer denied Personal Care Aide (PCA) Services: Split Shift, 24 Hours per Day, 7 Days per Week.
The determination is overturned. 

The patient is a male with a past medical history of atrial fibrillation, benign prostatic hyperplasia (BPH), congestive heart failure, dementia, depression, hypertension, chronic kidney disease, glaucoma, gastroesophageal reflux disease (GERD), chronic oxygen use, chronic foley catheter, bowel incontinence, melanoma, chronic anticoagulation, and diabetes mellitus type 2 who had personal care aide (PCA) services 24 hours/day, 7 days/week, live-in. The patient was admitted to the hospital with urosepsis and pressure ulcers with subsequent transfer to rehabilitation. The patient underwent a universal assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, and shopping while maximum assistance with tasks of managing finances, managing medication, transportation, bathing, dressing lower body, and toilet use. With tasks of phone use, personal hygiene, dressing upper body, walking, locomotion, and transfer to the toilet the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating. Notes from the assessment stated the patient had a pressure ulcer in the sacral region 3.3 times (x) 0.8-centimeter (cm) x 0.1 cm and was receiving wound care 3 times a week. There was a request for an increase in PCA services. 
The patient had an office visit with his primary care physician (PCP) and the PCP provided a letter requesting an increase in home care due to his rapidly deteriorating mental state, physical health, and functional status. The provider also stated the patient had severe mental deterioration due to progressive dementia and the patient could not reposition himself in his bed and was prone to bed sores. In addition, the provider stated the patient had urinary and fecal incontinence which required the use of diapers and required multiple daytime and nighttime changes of soiled linens to prevent skin irritation and rash. The provider also stated the patient required human assistance in bed and needed to be turned and repositioned bi-hourly as to prevent the development of pressure ulcers. 
At issue is the medical necessity of Personal Care Aide (PCA) Services: Split Shift, 24 Hours per Day, 7 Days per Week.

The requested health service/treatment of Personal Care Aide (PCA) Services: Split Shift, 24 Hours per Day, 7 Days per Week is medically necessary for this patient.
The patient has a sacral ulcer and the patient's medical provider documents the medical necessity of turning and repositioning every two hours. The patient's overnight activities of daily living (ADL) care needs would not allow a PCA 5 hours of uninterrupted sleep. In addition, the patient's living arrangements are not conducive to the PCA being able to obtain 5 hours of uninterrupted sleep. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as the insurer indicated in denial notice. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split shift, 7 days/week, are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.