Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, osteoarthritis, heart failure, and hemiplegia. 
Treatment: Increase Personal Care Aide Services (PCA) To Split Shift For a Total of 168 Hours Per Week. 

The insurer denied: Increase Personal Care Aide Services (PCA) To Split Shift For a Total of 168 Hours Per Week. 
The denial is upheld. 

This patient is an elderly male. His medical conditions include dementia, osteoarthritis, heart failure, and hemiplegia. Denial of increase personal care aide services (PCA) to split shift for a total of 168 hours per week is being appealed. The health plan approved 10 hours per day, seven days per week, for a total of 70 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 5 months ago shows severely impaired cognition and functional status. The patient requires maximal assistance to total dependence with all activities of daily living (ADLs). He has frequent bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with lower body dressing, toilet transfer, bathing, walking, and locomotion. A letter from the patient's provider notes the patient has progressive dementia, chronic shortness of breath, muscle weakness, incontinence, and repeated urinary tract infections. He was recently hospitalized and now is in a nursing home. He requires assistance with all activities of daily living. He is unable to stand without assistance. He requires constant care or will be confined to a nursing home. A letter from another provider notes the patient has numerous health conditions. He needs supervision with all daily activities. He is at high risk of falling. He requires constant assistance and supervision. 

The Increase Personal Care Aide Services (PCA) To 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 who 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. Denial of increase personal care aide services (PCA) to split shift for a total of 168 hours per week is being appealed. The health plan approved 10 hours per day, seven days per week, for a total of 70 hours per week. This patient has multiple chronic conditions, including recent hospitalization. Uniform Assessment System (UAS) evaluation completed 5 months ago shows the patient needs maximal assistance to total dependence with all activities of daily living (ADLs). He has bowel and bladder incontinence. 
Appeal statements support that the patient needs assistance with all activities of daily living and constant supervision. The information provided does not support that the patient has continuous needs, such as assistance with toileting, transfers, and turning/repositioning that would not give the aide five hours daily of uninterrupted sleep during the aide's shift. Personal care aide is not indicated for management of chronic medical conditions or for safety supervision. Therefore, the requested increase in personal care aide to split shift for a total of 168 hours per week is not medically necessary.