Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia and arthritis
Treatment: Increase in Personal Care Aide (PCA) Services For a Total of 168 Hours Per Week (split shift)
The insurer denied the increase in Personal Care Aide (PCA) Services for a total of 168 hours per week (split shift).
The denial is overturned.

The patient is a female. Her medical conditions include dementia and arthritis. She lives with her son in an apartment. Her son assists with ADLs (activities of daily living) on the weekends only. Denial of increase personal care aide (PCA) services for a total of 168 hours per week (split shift) is being appealed. The health plan partially approved an increase to 45.5 hours/week.

Uniform Assessment System (UAS) evaluation completed showed minimally impaired cognition and functional status: total dependence with housework, managing finances, and shopping; maximal assistance with meal preparation, and managing medications; extensive assistance with bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility; limited assistance with phone use; and supervision with eating. Her ADLs status has deteriorated in approximately the last 90 days. She has frequent bowel and bladder incontinence. Compared to UAS evaluation completed previously, there was a decline in cognition from modified independent and a decline in functional status with personal hygiene, dressing, walking, locomotion, toilet use, bed mobility and eating. There has also been a progression with incontinence. DME (durable medical equipment) includes a cane, walker, shower chair, shower grab bar, incontinent supplies, and PERS (personal emergency response system).

An appeal letter from the patient's provider notes the patient has severe progressive dementia and only knows her name, impaired vision, bilateral knee arthritis, a history of falling, chronic diarrhea and vomiting. She takes off her diaper, eats improperly, needs assistance with transfers and ambulation, opens the door to go outside, and has an irregular sleep cycle. She had a recent fall when getting out of the bed to go to the bathroom and laid on the floor for hours. It is noted that the patient is not safe to be alone.

An Advocacy Report notes the patient needs assistance with ADLs as already accounted for in the UAS evaluation. Her overnight needs are unpredictable.

Yes, the requested increase in personal care assistance hours to 168 hours/week, split shift, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

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. The denial of increase in PCA services for a total of 168 hours per week (split shift), is being appealed. The health plan partially approved an increase to 45.5 hours/week.

This patient has multiple chronic medical conditions, including progressive dementia. UAS evaluation completed shows the patient requires assistance with all ADLs except supervision with eating. Compared to UAS evaluation completed previously, there was a decline in cognition from modified independent and a decline in functional status with personal hygiene, dressing, walking, locomotion, toilet use, bed mobility and eating. There has also been a progression with incontinence. Appeal statements note the patient has progressive decline in dementia and needs increased PCA for assistance with ADLs and supervision. She has a history of falls when attempting to transfer without assistance. This patient's decline in cognition, functional status, and incontinence has resulted in the need for significant assistance with ADLs and personal care throughout the day and night. The patient's needs cannot be met with the approved PCA 45.5 hours/week. The proposed increase in PCA services to a total of 168 hours per week (split shift) is medically necessary.