Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incontinence/Urinary/Bladder Control
Treatment: Personal Care Assistance Services, 7 days per week, 24 hrs per day (split shift) 
The health plan denied: Personal Care Assistance Services, 7 days per week, 24 hrs per day (split shift) 
The determination is: Upheld 

The patient is a female with a history of dementia, age-related weakness, hypertension, arthritis, scoliosis, chronic kidney disease, bladder incontinence, and bowel incontinence. She lives alone in a private home; her daughter lives 2 hours away. She has durable medical equipment in her home. The patient was previously approved for Personal Care Assistance (PCA) services 125 hours per week. The patient and her care team requested PCA services 7 days per week, 24 hours per day (split shift). 
A video Uniform Assessment System (UAS) was completed last year. The patient was assessed at total dependence for the tasks of meal preparation, ordinary housework, managing finances, phone use, use of stairs, shopping, equipment management, and bathing. She requires maximal assistance for tasks of transportation, personal hygiene, dressing her upper body, dressing her lower body, and toilet use. She requires extensive assistance for tasks of walking, locomotion, transfer to the toilet, and bed mobility. She requires limited assistance for the task of eating. A tasking tool was used to determine that she requires 44.18 hours of aide service per week.
A subsequent video UAS was completed this year. The patient was assessed at total dependence for tasks of meal preparation, ordinary housework, managing finances, shopping, and transportation. She requires maximal assistance for tasks of managing her medications, phone use, use of the stairs, equipment management, bathing, dressing her upper body, and dressing her lower body. She requires extensive assistance for tasks of personal hygiene, walking, locomotion, transfer to the toilet, toilet use, and bed mobility. She requires limited assistance only for the task of eating.
The patient's daughter provided a letter of support stating that the patient is unable to do any activities of daily living (ADLs) without full assistance.
The patient's primary care provider (PCP) provided a letter of support. Per her PCP, the patient has been receiving 24 hour care at home with a family friend covering the 43 hours per week that were not provided by her home health care agency. Her PCP states that this family friend is relocating and will not be able to fill this gap in care. Her PCP states that due to severe dementia and infirmity with limited capacity, she cannot be left alone and is unable to provide any care for herself.
At issue is the medical necessity of Personal Care Assistance Services, 7 days per week, 24 hrs per day (split shift).

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

The requested health service/treatment of Personal Care Assistance Services, 7 days per week, 24 hrs per day (split shift) is not medically necessary for this patient.
Per New York Codes, Rules, and Regulations section 505.14, a live-in personal care aide must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. Split-shift care requires evidence that a PCA would be unable to receive 5 hours of uninterrupted rest while caring for the patient. While the patient requires hands-on assistance for many ADLs and instrumental activities of daily living (IADLs), there is no documentation showing that this patient currently requires frequent overnight assistance with specific ADLs or IADLS. There were no night logs of care required overnight and no physician orders for frequent repositioning. Therefore, there is insufficient evidence of medical necessity for the requested increase in PCA hours. Additional hours are not provided when tasks are not being performed and for safety monitoring and supervision only.