Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glaucoma
Treatment: Increase in Personal Care Assistance (PCA) hours from 7 days/week, 12 hours/day (84 hours/week) to 7 days/week, 24 hours/day - split shift
The health plan denied the increase in PCA hours from 7 days/week, 12 hours/day (84 hours/week) to 7 days/week, 24 hours/day - split shift.
The determination is overturned.

The patient is a female with medical history notable for diabetes, legal blindness, incontinence, and dementia. The patient is currently approved for 12 hours/day, 7 days/week (84 hours/week) of personal care assistance (PCA) services. The patient and her care team requested an increase to 24 hours/day (2-12-hour split-shift), 7 days/week (168 hours/week), and this request was denied by the health plan. This denial is the subject under review.

The patient's eye doctor provided a letter for this review. The letter states that due to the patient's severe open angle glaucoma, her best corrected visual acuity is hand motion in the right eye and 20/150 in the left eye.

The patient's son provided a letter of support for this appeal. The letter states that the patient has been becoming weaker and fragile. Her home health providers have had to "catch" her from falling on several mornings. She previously had a fall and suffered an injury resulting in a 3-month hospitalization and rehabilitation. She is mostly bed-bound at this time and wears diapers, which in her current state need to be worn for 13 hours overnight without changing due to lack of personal care hours overnight. The patient does not have any informal support when her aide is not available.

The patient's physician provided a letter of support for this appeal. The letter states that the patient has had a dramatic deterioration in her functional status after recent falls. She is now completely reliant on others for activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She has urinary incontinence and requires frequent diaper changes during the day and night. The physician feels that it is medically necessary to have split-shift PCA to cover her nighttime personal care needs.

A Uniform Assessment System (UAS) was available for review. The patient lives alone in her apartment. She was alert and oriented to person and place only; she is forgetful with recall 1/3 at five minutes. She is not able to complete a procedural task. She is not able to manage her own care. For her IADLs, she requires total dependence or maximal assistance for all. For her ADLs, she requires maximal assistance or extensive assistance for all. She requires maximal assistance for transfers and can walk only a short distance with weight bearing support and a walker. She is frequently incontinent of urine and infrequently incontinent of stool. Compared to a prior assessment, she showed a significant decline in functional status.

At issue is the medical necessity of increasing PCA hours from 7 days/week, 12 hours/day (84 hours/week) to 7 days/week, 24 hours/day - split shift.

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

The requested health service of increase in PCA hours from 7 days/week, 12 hours/day (84 hours/week) to 7 days/week, 24 hours/day - split shift is medically necessary for this patient.

The patient is essentially bed bound and has dementia and urinary incontinence. She is completely reliant on others to complete all personal care tasks. She cannot direct her own care. Her personal care needs can be expected to be continuous and unscheduled throughout the day and night. She will require prompt changing of soiled diapers overnight to prevent skin breakdown and/or infection. The requested increase in personal care hours is medically necessary at this time.