Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, dementia, insomnia and heart failure
Treatment: Personal care aide (PCA) services for 7 days per week two 12-hour shifts per day (split shift)
The insurer denied coverage for personal care aide (PCA) services for 7 days per week two 12-hour shifts per day (split shift)
The denial is overturned.

This elderly female has substantial functional impairment associated with several medical conditions and requires assistance with all daily activities. The patient lives with her husband. She had been receiving personal care aide (PCA) services 24 hours per day split shift. The most recent Uniform Assessment System (UAS) provided for review was done. The functional status report indicated total dependence for most instrumental activities of daily living (IADLs), except managing medications and phone use (maximal assistance). For activities of daily living (ADLs), it was reported that the patient is bedbound; walking, locomotion and toilet transfer did not occur during entire period. She is totally dependent for bathing, dressing upper and lower body, personal hygiene, toilet use/incontinence care; she needs maximal assistance for bed mobility and eating. 

The patient is high risk for pressure ulcers. She needs maximal assistance for bed mobility; and she has no bladder or bowel control. Her body mass index (BMI) (17.7) based on height/weight in the UAS indicates patient is underweight which suggests impaired nutrition, another risk factor for pressure ulcers. These risk factors also can result in poor outcome if pressure ulcers occur (e.g., impaired nutrition and chronic soiling of sacral/buttock ulcer from incontinence can interfere with healing). Pressure ulcers can cause pain; may result in complications (e.g., infection/sepsis) and possibly require surgical intervention. Prevention of pressure ulcers for an elderly person with multiple risk factors (as noted above) and co-morbidities (in this case, cardiac disease, dementia) is a priority. Pressure reducing mattress can help, but repositioning is needed for full pressure relief of high-risk areas (e.g., sacrum/buttocks, hips). The UAS indicates turning/repositioning program is in place, but the frequency was not noted.  The physician's letter indicates repositioning is needed every 2 hours to prevent skin injury. The patient depends on the aide for repositioning, and so with a live-in aide, the patient would remain in one position during the aide's 5-hour sleep period, and possibly in a wet soiled diaper for at least part of the 5 hours. Incontinence care and repositioning can occur at the same time; but if more than 2-3 hours pass without the need for incontinence care, then repositioning as a separate task is indicated.

The patient needs assistance for all routine IADLs and ADLs; and for ADLs that occur at unscheduled and recurring times of the day and night (including toileting/incontinence care; bed mobility). Based on available information (i.e., UAS reports and physician's letter), decreasing PCA services cannot be medically justified for the patient. The patient's care plan would be less effective, with risk of harm to the patient (as discussed in this report). It does not appear the patient's daytime and nighttime personal care needs can be met with live-in services, which includes 5 hours of uninterrupted sleep per day for the aide (plus 3 more hours of sleep for the aide at variable times during the day or night). Therefore, PCA 24 hours per day continuous services (split shift) is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care aide (PCA) services for 7 days per week two 12-hour shifts per day (split shift) services is substantiated.