Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, Parkinson's Disease
Treatment: Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week - 12 Hours per Day, 7 Days per Week / 12 Hours per Day, 7 Days per Week (Split Shift)
The insurer denied Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week - 12 Hours per Day, 7 Days per Week / 12 Hours per Day, 7 Days per Week (Split Shift).
The determination is upheld.

The patient has a past medical history of dementia, urinary incontinence, Parkinson's disease, chronic kidney disease, osteoarthritis, hypertension, hypothyroidism and gastroesophageal reflux disease (GERD) who had been assigned personal care assistant (PCA) services 6 hours/day, 7 days/week based on an assessment performed telephonically.
There was a request to increase PCA services and the patient underwent an in person assessment assessing the patient at total assistance with tasks of ordinary housework while maximum assistance with tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, and dressing lower body. With the tasks of managing finances, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and bed mobility the patient was assessed at extensive assistance while limited assistance with the task of toilet use. The patient was assessed at supervision with task of eating and independent with task of phone use.
The insurer provided an initial adverse determination denial notice denying request to increase PCA services stating the patient's son requested an increase because the patient had a tremendous decline in health and the patient was now bedbound and needed more assistance with turning, repositioning, incontinence care, transferring to wheelchair, dressing, bathing, and medications. The denial also stated the patient lived with her spouse and children who were supportive and involved in her care, the insurer made recommendation for physical therapy as well as evaluation for durable medical equipment (DME). Lastly, the denial stated the current PCA services were appropriately and safely meeting the patient's personal care needs.
The patient's psychiatrist provided a letter stating the patient's diagnoses and based on the patient's mental condition that has shown memory deterioration, decreasing of attention, impairment in memory, and difficulty to take care of herself and ability to perform personal hygiene, the patient needed close supervision during the day. The patient's primary care physician (or provider) (PCP) provided a letter documenting the patient diagnoses and the patient required assistance with bathing, grooming, dressing, transfers, ambulation, meal preparation, escorting to medical appointments, cleaning, laundry, and food shopping. The PCP also noted even though the patient has pre-poured a pillbox, the patient requires reminders several times throughout the day. The PCP letter also stated the patient required an aide to remind the patient to take her evening medicine including insulin, help prepare the patient for bed, and assist the patient with ambulation and transfer at unscheduled times throughout the day and until bedtime.
The insurer sent a final adverse determination denial notice partially denying the request to increase PCA services stating PCA services would increase to 8 hours/day, 7 days/week. The denial also stated the patient lived with her spouse and had a supportive son and daughter involved in her care and time had been allotted for housework, laundry, and meal preparation. In addition, the denial noted the DME the patient had in the home and additional hours are not provided when tasks are not being performed and therefore increasing PCA services was not medically necessary. The patient's advocate provided a letter stating the husband could not help the patient with anything as he was also very sick. The letter also stated the patient's children had limited involvement in the patient's care as they had full-time jobs and their own family. At issue is the medical necessity of Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week - 12 Hours per Day, 7 Days per Week / 12 Hours per Day, 7 Days per Week (Split Shift).

The services are not medically necessary.
Although there is documentation of worsening cognitive and functional status as well as an increase in assistance needs with multiple tasks there is no documentation of overnight care needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. There is no documentation from the patient's medical provider of the need of the patient to be turned and repositioned every 2 hours, therefore split shift services would not be medically necessary. 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 12 hours/day, 7 days/week and 12 hours/day, 7 days/week, split shift, to total 168 hours/week are not medically necessary for this patient.