Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, atrial fibrillation, pacemaker placement, 
syncopal episodes, polymyalgia rheumatica, and anxiety
Treatment: Personal Care Aide (PCA) Services 12 Hours Times Two Split Shifts, Seven (7) Days A Week
The insurer denied: Personal Care Aide (PCA) Services 12 Hours Times Two Split Shifts, Seven (7) Days A Week
The denial is upheld.

The patient is an elderly female with hypertension, atrial fibrillation, pacemaker placement, syncopal episodes, polymyalgia rheumatica, and anxiety who is requesting an increase in personal care aide (PCA) services to two 12-hour split shifts, seven days a week, which represents an increase from the patient's existing services which include a personal care aide (PCA) live-in three days per week and personal care aide (PCA) services 9 hours per day for four days per week.
A Uniform Assessment System (UAS) evaluation completed recently shows the patient has moderately impaired cognition. She is totally dependent for meal preparation, shopping, housework, toilet use, walking, and bathing. She requires maximal assistance with medication management, hygiene, dressing the upper body, toilet transfer and eating. A tasking tool dated three months ago estimated total hours needed of 5 hours and 55 minutes, seven days per week. The plan partially denied the request for split shift personal care aide (PCA) services and instead approved live-in personal care aide (PCA) services, seven days per week. The plan noted that needs could be met with a live-in aide. The plan upheld the decision in a final adverse determination letter noting that the request was not medically necessary, again noting that personal care aide (PCA) live-in services are adequate to meet the patient's needs.
The patient's representative has appealed the request with the rationale that the patient has "sundowning" at night and is sometimes awake for up to 20 hours a day. The appeal also notes that the patient has worsening dementia with anxiety and confusion requiring active care.

The proposed Personal Care Aide (PCA) Services (two 12 -hour split shifts, seven days a 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. The request is for an increase in home/personal care to two 12-hour split shifts, seven days per week. The time-based tool completed three months ago reflects that allocated time for each of the patient's activities of daily living amounts to 41 hours and 24 minutes per week, which is covered by the live-in aide approved by the plan. The submitted documentation does not reflect which activities of daily living cannot be completed with a live-in aide. Moreover, there is no evidence of frequent night-time needs (e.g. frequent turning, frequent toileting needs) that would prevent a 
live-in aide from obtaining five hours of uninterrupted sleep during an eight-hour period of sleep. While the appeal information notes that the patient has confusion at night, personal care services are not covered for supervision and safety concerns, per New York State Guidelines. Based on the available information, personal care services with a live-in aide seven days per week are sufficient to adequately meet the patient's needs. Thus, the increase in personal care aide (PCA) services to two 12-hour split shifts, seven days a week is not medically necessary.