Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, hypertension, irritable bowel.
syndrome, and osteoarthritis.
Treatment: Increase Personal Care Assistance Services from 84 Hours per Week to 24 Hours per Day Seven Days per Week, Split Shift, for a Total of 168 Hours per Week.
The insurer denied the Increase Personal Care Assistance Services from 84 Hours per Week to 24 Hours per Day Seven Days per Week, Split Shift, for a Total of 168 Hours per Week.
The denial is upheld.

This female has medical conditions including dementia, hypertension, irritable bowel syndrome and osteoarthritis.  She lives alone.  She is appealing denial of increase in Personal Care Assistance Services from 84 hours per week to 24 hours per day, seven days per week, split shift for a total of 168 hours per week.  Additional hours were requested for nighttime toilet needs and safety with ambulating.  Also, the patient is noted to be delusional during the night.  

Uniform Assessment System (UAS) evaluation completed on shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, managing finances, shopping, and transportation; extensive assistance with managing medication, phone use, bathing, personal hygiene, dressing, toileting, walking, and locomotion; supervision with eating; and independent with bed mobility.  The patient was occasionally incontinent of bladder.  

An appeal statement dated from Social Worker states the patient's chronic conditions make her dependent for assistance with activities of daily living (ADLs).  It notes the patient has had an increase in incontinence and cognitive decline.  It notes the patient needs assistance with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation.  

A letter from the provider notes the patient has cognitive deficits and visual hallucinations.  She had a recent fall.  It notes the patient is alone at night.  

A letter from another provider notes the patient needs assistance with activities of daily living (ADLs).  It notes the patient is incontinent of bowel and bladder during the day and night.  It states her condition is deteriorating.  

A letter from the patient's sister states it is difficult for her to assist her sister.

No, the proposed treatment, Increase in Personal Care Assistance Services from 84 Hours per Week to 24 Hours per Day Seven Days per Week, Split Shift, for a Total of 168 Hours per Week, is not medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.

This patient has several chronic conditions including dementia with hallucinations.  She lives alone.  She is appealing the denial of an increase in Personal Care Assistance Services from 84 hours per week to 24 hours per day, seven days per week, split shifts for a total of 168 hours per week.  Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLS), expect bed mobility and eating.  She has occasional bladder incontinence.  Appeal statements request assistance for safety due to nighttime delusions, hallucinations, and falls.  These statements also note the need for assistance with toileting during the night.  The documentation supports a deterioration in the patient's dementia, which affect manifest during the nighttime.  The documentation does not support the need for medical services during the nighttime.  Personal care aide (PCA) is not indicated for supervision or when no services are being performed.  The approved personal care aide (PCA) 84 hours per week is sufficient to meet the patient's needs for assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  The proposed increase to personal care aide (PCA) 24 hours per day, seven 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.