Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, diabetes and arthritis
Treatment: Increase Personal Care Aide (PCA) Level 2  For a Total of 168 Hours Per Week
The insurer denied the Increase Personal Care Aide (PCA) Level 2  For a Total of 168 Hours Per Week.
The denial is overturned.

The patient is a female. She has conditions including Alzheimer's disease, diabetes and arthritis.  This is an appeal of denial of PCA (personal care aide) services, split-shift, for a total of 168 hours per week.  She has been approved for 55 hours per week.

The patient lives with her daughter.  She has a cane, shower chair, walker, and incontinent supplies.  The adverse determination notice shows that the patient needs assistance with dressing, personal hygiene, bed mobility, walking, locomotion, bathing, toilet transfer, eating, meal preparation, medication management and housework based on UAS (Uniform Assessment System) evaluations.

An appeal letter dated from the provider states 24-hour, split-shift care is needed due to dementia and assistance with ADLs (activities of daily living).  The letter notes that the patient needs help during the night for toileting, food/drink and confusion concerns.  She has falls due to mobility limitations.  The letter notes that live-in PCA (personal care aide) would not get five hours of sleep, and that the patient needs constant supervision because she is a danger to herself.  Appeal letters from the patient's children note that the patient needs assistance with the restroom at night. They note that the patient is incontinent and needs to go to the bathroom up to six times per night.  She needs assistance with bed transfer, bathing, dressing, and ambulation.  She uses a cane or walker.

Yes, the increase in Personal Care Aide service to a total of 168 hours per week is medically necessary.
Medically necessary services are those which are:
- safe 
- effective
- generally accepted national standard of medical practice 
- not provided primarily for convenience of the patient or the practitioner 
- the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested health service is medically necessary, because it is consistent with generally accepted national standard of medical practice.

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 provider five hours daily of uninterrupted sleep during the aide's shift. The requested PCA (personal care aide) services at 24-hours per day, split shift was denied.  She has been approved for 55 PCA (personal care aide) service hours per week.

This patient has multiple chronic conditions, including Alzheimer's dementia.   Appeal letters were provided from the patient's doctor and children.  The appeal indicates that the patient has decline in physical functioning.  The patient needs assistance with dressing, personal hygiene, bed mobility, walking, locomotion, bathing, toilet transfer, eating, meal preparation, medication management and housework.  The patient also has incontinence and is noted to need the bathroom several times nightly.  She is incontinent of bladder and has the need for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living), including ambulation/transfers for toileting during day and night.  This patient has continuous needs that cannot be met with the approved PCA (personal care aide) services at 55 hours per week.  The proposed increase in PCA (personal care aide) to a 24-hour per day, split-shift is medically necessary to meet this patient's need for assistance with ADLs (activities of daily living) and personal care.