Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease
Treatment: Increase in personal care services from 84 hours to 24 Hour(s) per Day (Split Shift). 
The insurer denied an increase in personal care services from 84 hours to 24 Hour(s) per Day (Split Shift). 
The determination is upheld.

This is a female patient with a history of Parkinson's Disease, Parkinson's related cognitive dysfunction, osteoarthritis, lumbar disc disease, osteoporosis, gastritis, chronic vertigo, and a pelvic mass. The patient lives alone in a one-bedroom apartment. The patient was previously approved for 84 hours per week of Personal Care Assistance (PCA) services. The patient and her care team requested PCA services 24 hours per day (split shift). This increase was denied by the Plan, and this denial was appealed by the patient's daughter.
An in-person Uniform Assessment System (UAS) was completed. The patient was assessed at total dependence for tasks of meal preparation, ordinary housework, managing finance, and shopping; maximal assistance for tasks of managing medications, transportation, bathing, dressing lower body, transfer toilet, toilet use; extensive assistance with task of phone use, persona hygiene, dressing upper body, walking, and locomotion; and limited assistance with bed mobility and eating. A tasking tool was used to determine that she requires 49.58 hours of aide service per week.
The patient's primary care physician (PCP) provided a letter of support. He states that the patient is homebound, requires 24-hour care, and cannot be left alone.
The patient's daughter provided a letter of support. She states that her mother requires round-the-clock assistance. She states that her mother has difficulty with balance and recurrent falls with injuries, decreased strength in her right hand, and is legally blind in her right eye. At issue is the medical necessity of an increase in personal care services from 84 hours to 24 Hour(s) per Day (Split Shift). 

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, Personal Care Assistance services 24 hours per day (split shift) is not medically necessary.
The question being posed is whether split-shift care is medically necessary for this patient.  There is no evidence that split shift care is medically necessary.  Split shift care would by definition involve 24-hour care and can only be approved if an aide is unable to receive 5 hours of uninterrupted sleep.  While the patient requires hands-on assistance for many activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) there is no documentation showing that the patient currently requires frequent overnight assistance with any specific ADLs or IADLS. There were no night-logs of care required overnight and no physician orders for frequent repositioning. Therefore, there is insufficient evidence of medical necessity for the requested increase in PCA hours. Additional hours are not provided when tasks are not being performed and for safety monitoring and supervision only.