Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease
Treatment: Home Health Care
The health plan denied the requested PCA (Personal Care Assistant) services as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a past medical history significant for Alzheimer's disease, hallucinations, memory loss, parasomnia, hypertension, hyperlipidemia, osteoarthritis, back pain, urinary and fecal incontinence, and dizziness. She is wheelchair bound and bedbound. The patient is currently receiving personal care assistance (PCA) services, live in 24 hours a day  (times) 7 days a week. The patient is requesting split shift services 12 hours per day 27 days per week.
At issue is the medical necessity of the requested PCA services.

The health plan's determination of medical necessity is upheld, in whole.

No, the requested health service is not medically necessary for this patient.
Additional services, split shift 12 hours a day 27 days a week is not medically necessary. Current PCA services of 24 hour a day living are adequate to meet the patient's needs.
The patient is a female with progressive memory loss, and a decrease in cognitive and motor function. She is bedbound. The patient's physical status and cognitive status have declined since the last evaluation. On the most recent evaluation/tasking tool it was recommended the patient have 45 hours a week as services. There was no nighttime log included for evaluation. There were no services noted which necessitated frequent nighttime services such as turning for a noted bedsore. The patient has ongoing issues with incontinence.
The patient's personal care hours are currently 24 hours a day live-in services. Typically, the plan will allow for 5 hours of uninterrupted sleep for live in services. It is not medically necessary to increase the patient's hours to a 24-hour split shift service. This was based on the most recent Uniform Assessment System (UAS) assessment. There were no changes with the patient's abilities to perform functions including bed mobility, bathing, hygiene, dressing upper and lower extremity, walking, eating, meal preparation, ordinary housework, and medication management. Bladder and bowel incontinence is noted. Personal care hours are currently authorized in the amount to meet the patient's needs.
The son's statement states that the patient is bedbound, and incontinent and therefore requires repositioning.  Repositioning is typically medically necessary for certain conditions such as decubitus ulcers.  There is no mention of any decubitus ulcers which would necessitate frequent turning during the middle of the night.  Also, there is ample time allowed for in the services provided that the aide could be available at night and sleep during the day. This leaves ample time for an aide to sleep.
Similarly, a letter from her physician states that the patient needs services continuous at night to monitor her behavior at night due to parasomnia.  Monitoring behavior, companionship and safety monitoring are typically noncovered services unless medically necessary activities of daily living (ADL) is being performed concurrently.