Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Personal Care Aide (PCA) Services For A Total Amount of 168 Hour(s) Per Week (Split Shift)
The insurer denied the Increase Personal Care Aide (PCA) Services For A Total Amount of 168 Hour(s) Per Week (Split Shift)
The denial is overturned

The patient is a female. She has several chronic conditions, including dementia. She lives alone. Denial of increase personal care aide (PCA) services for a total amount of 168 hours per week, split shift, is being appealed. The health plan approved PCA (personal care aide), live in.

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and managing finances; maximal assistance with managing medications, bathing, lower body dressing, walking, locomotion, and toileting; extensive assistance with personal hygiene, upper body dressing, and bed mobility; and supervision with eating. The patient has bowel and bladder incontinence. She ambulates with assistance of a walker. Compared to UAS (Uniform Assessment System) evaluation completed previously, there is no functional decline.

A letter from the patient's advocate reports the patient's functioning has declined and she cannot be left alone. The patient already has a live-in aide that is insufficient due to overnight needs.

A letter from the patient's provider reports the patient requires assistance with ADLs (activities of daily living) and is at risk of falling. She needs changing frequently throughout the day and night to protect skin breakdown.

A letter from the aid reports the patient does not sleep through the night. She needs assistance with toileting and repositioning. Night shift logs shows the patient gets assistance with toileting and water approximately every 2 hours.

Yes, the Increase Personal Care Aide (PCA) Services For A Total Amount of 168 Hour(s) Per Week (Split Shift) is medically necessary.

Personal care service 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 personal care services 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. Denial of increase personal care aide (PCA) services for a total amount of 168 hours per week, split shift, is being appealed. The health plan approved PCA (personal care aide) live in.

The patient has several chronic conditions. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living), except eating. She has bowel and bladder incontinence. The appeal statements report there has been a decline in the patient's functioning, and she requires assistance with ADLs (activities of daily living) throughout the day and night, including frequent toileting and changing. Night time logs support frequent assistance throughout the night. This patient has significant physical impairments and requires frequent assistance with all ADLs (activities of daily living), except eating. The approved PCA (personal care aide) live-in is insufficient to meet the patient's needs. The requested PCA (personal care aide) for a total amount of 168 hours per week, split shift, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The requested increase in personal care aide to 168 hours/week, split shift, is medically necessary.