Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied Personal Care Aide (PCA) Level 2: 12 hours per day-7 days a week; 12 hours per day-7 days a week(split shift)- a total of 168 hours per week. 
The denial is upheld. 

The patient is a female with a past medical history of diabetes mellitus type 2, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), dementia, bladder incontinence, bowel incontinence, glaucoma, depression, chronic urinary tract infection (UTI), chronic kidney disease, atrial fibrillation, osteoarthritis, and transient ischemic attack (TIA) who had been assigned personal care aide (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week based on telephonic assessment tool assessing the patient at total assistance with tasks of ordinary housework and shopping while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, transportation, bathing, dressing lower body, walking and locomotion. With tasks of phone use, personal hygiene, dressing upper body, transfer to the toilet, toilet use, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. The patient had minor injury following a fall.
The patient's primary care physician (or provider) (PCP) provided a letter  stating the patient had a history of falls due to her unsteady gait and frequently got up during the night and needed to be supervised to prevent hurting herself. 
The insurer sent initial adverse determination denial notice partially denying request to increase PCA services by increasing PCA services to 24 hours/day, live-in, 7 days/week. The patient's daughter appealed the denial decision stating the patient needed 24-hour care broken down into 2 shifts because this allows her home care worker to have a 5-hour rest. The appeal also stated the patient suffered from dementia and during the home care worker's sleep could fall and hurt herself.
The insurer sent final adverse determination denial notice denying request to increase PCA services to 12 hours/7 days times (x) 2, split-shift, 7 days/week stating the patient's daughter and daughter-in-law were supportive and involved in her care, the patient had adaptive equipment in the home, and granting additional hours were not provided when tasks were not being performed and for safety monitoring and supervision.
At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 12 hours per day-7 days a week; 12 hours per day-7 days a week(split shift)- a total of 168 hours per week.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day-7 days a week; 12 hours per day-7 days a week(split shift)- a total of 168 hours per week is not medically necessary for this patient.
The patient has an increase in care needs when comparing the assessment to the recent assessment but there was no documentation of overnight needs. There is no documentation that the patient requires turning and repositioning every 2 hours or that the patient has ADL needs outside of assistance for safety and supervision. There were no overnight logs with times of tasks to show the patient required assistance with ADLs overnight at an interval that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services would be for safety and supervision. 
Therefore, the requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day-7 days a week; 12 hours per day-7 days a week(split shift)- a total of 168 hours per week is not medically necessary for this patient.