Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma, hypertension, chronic kidney disease, gout, osteoarthritis, and atrial fibrillation
Treatment: Personal Care Assistance (PCA) services: two 12 hour (split shift) 7 days/week, for a total of 168 hours/week
The insurer denied the PCA services: two 12 hour (split shift) 7 days/week, for a total of 168 hours/week.
The denial is overturned.

This elderly female patient has conditions including asthma, hypertension, chronic kidney disease, gout, osteoarthritis, and atrial fibrillation. The denial of personal care assistance PCA) services, two 12 hour (split shift), 7 days/week, for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. Uniform Assessment System (UAS) evaluation completed 2 months ago shows the patient requires extensive assistance to total dependence with all activities of daily living (ADLs), except limited assistance with bed mobility and eating. Compared to UAS evaluation completed last year, there has been a decline in functional status with meal preparation, housework, managing finances and medications, personal hygiene, walking, locomotion, toilet transfer, and eating. The patient's cognitive functioning has declined to be moderately impaired. She is incontinent of bowel and bladder. A statement from the patient's designee notes she is homebound and cannot independently perform ADLs. She uses a rollator for ambulation. She has a recent diagnosis of cellulitis and was discharged to rehab 3 months ago. The nursing home found that the patient requires extensive side assistance to perform ADLs. A letter from the Provider notes the patient was discharged from rehab and now requires more assistance. She depends on others for instrumental activities of daily living (IADLs) and ADLs. Nighttime Log shows assistance with ADLs throughout the night.

The proposed treatment is medically necessary. 

Personal care service (PCS) 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 PCS 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. This patient has multiple chronic conditions. The denial of PCA services, two 12 hour (split shift), 7 days/week, for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. UAS evaluation completed 2 months ago shows the patient requires extensive assistance to total dependence with all ADLs, except limited assistance with bed mobility and eating. Compared to UAS evaluation completed last year, there has been a decline in cognition and in functional status with meal preparation, housework, managing finances and medications, personal hygiene, walking, locomotion, toilet transfer, and eating. She is incontinent of bowel and bladder. The medical records and appeal statements support the patient is dependent with all ADLs and requires frequent assistance with ADLs throughout the night. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved PCA services of 70 hours/week is insufficient to meet the patient's needs for assistance with ADLs. The proposed PCA services, two 12 hour (split shift), 7 days/week, for a total of 168 hours/week is medically necessary.