Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's disease, heart failure.
Treatment:  Increase Personal Care Aide (PCA) Services for the Total Amount of 168 Hours per Week (Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week [split shift]).

The insurer denied the increase in Personal Care Aide (PCA) Services for the Total Amount of 168 Hours per Week (Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week [split shift]).  The denial has been overturned.

The proposed treatment is medically necessary.      

This female patient has medical conditions that include Alzheimer's disease, daubers, hypertension, anemia, arthritis, heart failure, and psoriasis.  She was admitted at the beginning of the year for cholecystectomy.  The denial of an increase in personal care aide (PCA) services for the total amount of 168 hours per week, seven days a week, 12 hours per day, split shift, is being appealed.  The health plan approved 12 hours per day, seven days a week, for a total of 84 hours per week.

Uniform Assessment System (UAS) evaluation performed on at the beginning of the year shows severely impaired cognition and functional status of maximal to total dependence with all activities of daily living (ADLs).  The patient has bowel and bladder incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed previously, there has been a decline with lower body dressing, bathing, and bed mobility.  

A letter from licensed clinical social worker (LCSW) notes the patient is mostly bedbound and has developed a sacral ulcer.  She requires total assistance with activities of daily living.  She requires frequent assistance at night that includes toileting every one to two hours. She needs to be turned and repositioned every two hours.  

A letter from the patient's daughter notes the patient needs assistance with activities of daily living.  The patient cannot safely go to the bathroom and transfer.  She is at risk of falling.  She wakes up five times at night needing assistance with toileting and needs to be changed every two to three hours.  

A letter from the physician notes the patient is mostly bedbound.  She requires total assistance with activities of daily living. The patient requires frequent assistance at night that includes toileting every one to two hours. She needs to be turned and repositioned every two hours.  She lives alone and has no informal support.

This patient has multiple chronic conditions, including recent hospital admission for cholecystectomy.  The denial of an increase in personal care aide (PCA) services for the total amount of 168 hours per week, seven days a week, 12 hours per day, split shift, is being appealed.  The health plan approved 12 hours per day, seven days a week, for a total of 84 hours per week.  The health plan denied an increase in hours based on Uniform Assessment System (UAS) evaluations, noting that additional hours are not provided when no tasks are being performed and for safety monitoring and supervision.  However, Uniform Assessment System (UAS) evaluation completed at the beginning of the year showed the patient requires maximal assistance to total dependence with all activities of daily living.  She is incontinent of bowel and bladder.  Compared to Uniform Assessment System evaluation completed previously, there has been a decline with lower body dressing, bathing, and bed mobility.  The appeal statements support the patient is dependent with all activities of daily living and requires frequent assistance with toileting, transfers, and turning/repositioning.  This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift.  The proposed increase in personal care aide (PCA) to 168 hours per week, seven days a week, 12 hours per day, split shift, is medically necessary.