Appeal type: Medical necessity
Decision: Upheld

Diagnosis: memory loss, tremor, gait difficulty and sacral decubitus ulcer
Treatment: Increase Personal Care Assistance (PCA) Services To 24 Hours Per Day 7 Days Per Week (Monday-Sunday) Split Shift
The insurer denied the Increase Personal Care Assistance (PCA) Services To 24 Hours Per Day 7 Days Per Week (Monday-Sunday) Split Shift.
The denial is upheld.

The patient is a female. She has several chronic medical conditions. She has memory loss, tremor, gait difficulty and sacral decubitus ulcer. Denial of increase Personal Care Assistance (PCA) Services To 24 hours per day 7 days per week, split shift, is being appealed. She has been approved for 54 hours per week.

UAS (Uniform Assessment System) evaluation completed shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances, transportation, bathing, and lower body dressing; limited assistance with managing medications, personal hygiene, upper boy dressing, walking, locomotion, and toileting; supervision with phone use; and independent with eating. She has occasional bladder incontinence. She had no falls in the previous 90 days. Her PCA (personal care assistant) prepares meals before leaving. The patient is able to heat simple meals.

The patient's daughter stated more overnight hours are needed for toileting and medication administration. Progress notes show the patient is not able to cook, clean, or shop. She uses a walker for ambulation due to fear of falling. She has a progressive sacral decubitus ulcer. It is noted that she needs assistance with incontinence. It is noted she requires 24/7 care to assist with ADLs (activities of daily living) and safety.

No, the Increase Personal Care Assistance (PCA) Services To 24 Hours Per Day 7 Days Per Week (Monday-Sunday) Split Shift is not medically necessary.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase Personal Care Assistance (PCA) Services to 24 hours per day 7 days per week, split shift, is being appealed. She has been approved for 54 hours per week.

This patient has multiple chronic medical conditions. UAS (Uniform Assessment System) evaluation completed show the patient requires assistance with all ADLs (activities of daily living), except eating. She has occasional bladder incontinence. Progress notes indicate 24/7 care to assist with ADLs (activities of daily living) and safety. Personal care assistance is not indicated for supervision. The documentation provided does not support the need for continuous care. The approved personal care assistance 54 hours per week is appropriate and medically necessary to meets the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in personal care assistance to 24 hours per day 7 days per week, split shift, is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.