Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal - Osteoarthritis.
Treatment: Increase in Personal Care Assistance (PCA) services-Continuous Split Shift..
The insurer denied an increase in Personal Care Assistance (PCA) services-Continuous Split Shift.
The denial is upheld.

This patient is a male with a medical history notable for dementia, chronic pain, tremors, osteoarthritis, degenerative disc disease, type 2 diabetes, and ambulatory dysfunction (wheelchair bound). The plan approved 24-hour live in personal care services. However, the patient and his care team requested 24-hour split shift services.
A letter from the patient's primary care physician reviewed the patient's medical history, including a history of a fall which led to significant injury affecting mobility. The physician states that "due to patient complex medical condition it's recommended that he obtain home health services. Medically necessary and reasonable based on patient's condition and accepted standards of clinical practice. I suggest 24hours/7days for patient." 
A letter of support was also provided by the patient's social worker (SW). The SW reports that the patient does not sleep at night and yells or talks to himself due to dementia. The letter states he has incontinence and wears pull ups, but due to his dementia is unable to make his needs known when he requires a change. Additionally, the SW reports that "due to gastrointestinal (GI) issues, member coughs throughout the night and needs repositioning to reduce the coughing/mucous episodes." They state that the aides are currently not able to sleep at all and that that patient's personal care needs cannot be met with a minimum of 5-hour gap at night to allow the aide to rest. 
A Uniform Assessment System (UAS) was completed. The patient lives with his spouse who has been assisting with his care needs (although her ability to do so was described elsewhere as declining). He was alert and oriented times (x) 3. He is not able to follow a multi-step task. For activities of daily living (ADL)'s, he has total dependence for bathing and dressing lower body. He requires maximal assistance for hygiene, dressing upper body, toilet transfer, and toilet use. He requires extensive assistance for locomotion, bed mobility, and eating. He is wheelchair bound with tremors. His son manages his medications including daily insulin injections. 
At issue is the medical necessity of increase in Personal Care Assistance (PCA) services-Continuous Split Shift.

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

No, the requested health service/treatment of increase in Personal Care Assistance (PCA) services-Continuous Split Shift is not medically necessary for this patient.
The patient has extensive health needs, but there is no evidence of needs that require personal care overnight on the UAS. The SW notes bring up a few points. He has had some low blood sugars overnight, but this is best managed by working with his primary care physician (or provider) (PCP) on his insulin regimen to avoid low sugars overnight, rather than by feeding at nighttime. They state that he requires incontinence care overnight, but he has a urostomy bag and he is continent of stool. Urostomy changes are not personal care level care. He does not have a diagnosis of severe dementia that would require typical turning and positioning and his physician did not recommend this. In the absence of evidence of medical necessity for split-shift care, his needs would be cared for sufficiently by 24-hour live in personal care assistance at this time.
Therefore, the requested health service/treatment of increase in Personal Care Assistance (PCA) services-Continuous Split Shift is not medically necessary.