Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety Disorder, Osteoarthritis.

Treatment: Personal care services (PCS) 24 hours a day, 7 days a week (split-shift) for a total of 168 hours. 

The insurer denied  Personal care services (PCS) 24 hours a day, 7 days a week (split-shift) for a total of 168 hours. 

The determination is upheld. 

The patient has a past medical history of urinary incontinence, hypertension, constipation, gastroesophageal reflux disease (GERD), and osteoarthritis who had personal care assistant (PCA) services as a mutual case with her husband 13 hours/day, 7 days/week. There was a request to increase PCA services and the patient underwent an assessment via video assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, and bathing the patient was assessed at extensive assistance. The patient was assessed at limited assistance with tasks of managing medication, equipment management, dressing upper body, walking, locomotion, transfer toilet, and toilet use while independent with tasks of personal hygiene, bed mobility, and eating. 

The insurer sent an initial adverse determination denial notice denying the request to increase PCA services stating the plan had approved 24 hour, live-in PCA services but was denying PCA services 24 hours/day, split-shift. The denial stated the plan found the current services can meet all of the patient's needs. The patient appealed the denial decision and the patient's daughter provided a letter stating the patient and the patient's husband had coronavirus disease (COVID) and the patient's husband had been to the hospital many times and had to be in rehabilitation for 4 months and the patient's husband was no longer able to take care of himself. The daughter also noted the patient's health condition had quickly deteriorated. 

The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's medical diagnoses which include anxiety and the patient had been unable to sleep at night because she worries about her husband and therefore the patient is unable to sleep. The patient has declined mood stabilizing medication as she wants to be able to be awake enough to care for her husband at night. The primary care physician (or provider) (PCP) requested the combined home health aide services be increased to 24 hours/day, 7 days/week, and to 12-hour split shifts. The insurer sent a final adverse determination denial notice denying request to increase PCA services stating the patient did not have any skin breaks that required repositioning, the plan did not provide time for companionship, safety supervision, or when tasks were not being done. The patient's PCP provided another letter stating the patient's excessive worrying and inability to get a good night sleep has led to frequent palpitations and multiple gastrointestinal (GI) symptoms consistent with stress. The provider requested that the patient's spouse's hours be increased to 2- 12-hour shifts to accommodate both the spouse and the patient's individual needs. The daughter provided another letter to the insurer reiterating the patient and patient's spouse medical conditions and that both the patient and a home attendant take turns helping the patient's spouse and the patient is exhausted. The PCP provided another letter requesting an increase in the patient and her spouse's home health aide services to 2-hour split shift, 24 hours/day. 

At issue is the medical necessity of personal care services (PCS) 24 hours a day, 7 days a week (split-shift) for a total of 168 hours as a shared/mutual case with spouse. 

The services are not medically necessary for this patient. The patient requires assistance with ADLs and Instrumental activities of daily livings (IADLs) except for personal hygiene, bed mobility, and eating. The patient does not have documented overnight care needs that would not allow a PCA 5 hours of uninterrupted sleep. The patient has significant anxiety surrounding the care of her husband and is not able to sleep at night because of his care needs and if he receives adequate care the patient will be able to sleep better. The patient does not require frequent turning and positioning. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are not medically necessary for this patient.