Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vascular dementia, osteoarthritis
Treatment: Increase Personal Care Aide (PCA) Services for 
Total Amount of 168 Hours per Week (Split Shift)
The insurer denied: Increase Personal Care Aide (PCA) Services for Total Amount of 168 Hours per Week (Split Shift)
The denial is upheld.

This patient is an elderly female with multiple medical issues including vascular dementia, osteoarthritis, hip fracture, urinary incontinence, coronary artery disease, and hypertension. The request is for an increase in personal care aide (PCA) services for a total amount of 168 hours per week (split shift). An initial adverse determination from a few months ago denied the request for increased hours and noted that the currently approved 45.5 hours per week would be maintained. The plan noted that these hours were appropriately and safely meeting the patient's personal care needs. The plan then issued a final adverse determination which partially approved the request, increasing services to 8.5 hours per day, 7 days per week of personal care aide, level 2, for a total of 59.5 hours per week. The additionally requested hours were denied, with the plan noting that "additional hours are not provided when tasks are not being performed and for safety monitoring and supervision...." In an external appeal application, the patient's daughter argues "it is unsafe to leave her alone because she is not aware that she is doing something that is unsafe for her. She needs someone with her at all times to make sure she is safe." A physician letter notes that the patient has an inability to function without assistance and will benefit from split shift home health aide (HHA) hours. The letter further notes that the patient is at risk for future falls and re-hospitalization due to injury without adequate homecare (split shift). A nursing assessment dated a few months ago notes that the patient is totally dependent for meal preparation, housework, and shopping. She requires maximal assistance with managing medications, bathing, personal hygiene, dressing, walking, toilet transfer and toilet use, and bed mobility. She requires extensive assistance with eating. The plan's "Clinical Review Checklist" references a Client Task Sheet from a few months ago which estimated that 8.5 hours per day for 7 days were necessary to address the patient's needs.

The requested health service 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 in personal care aide (PCA) services for a total amount of 168 hours per week (split shift) from the currently approved 59.5 hours per week. The submitted documentation does not reflect which activities of daily living cannot be completed within the currently approved 59.5 hours per week. There is also no evidence of frequent night-time needs (e.g. frequent turning due to wounds, frequent toileting needs that are not improved with other measures). Time for housework, meal preparation, personal hygiene, shopping, toileting, and 
dressing, have already been accounted for in the 59.5 hours approved by the plan. The patient is also noted to have equipment at home to assist with her activities of daily living and keep her safe, including a rollator walker, shower chair, shower grab bars, wheelchair, hospital bed, and incontinence supplies. Notes from the patient's daughter and physician clearly indicate that additional hours are needed to maintain the patient's safety. Additional hours beyond those currently supplied by the plan would primarily be for safety and supervision; however, personal care services are not covered for supervision and safety concerns, per New York State Guidelines. Based on the available information, the plan's initial denial rationale is appropriate, and 59.5 hours per week of personal care aide, level 2, services are sufficient to meet the patient's needs. Thus, the increase in personal care aide (PCA) services for a total amount of 168 hours per week (split shift) is not medically necessary.