Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, hypertension (HTN), coronary artery disease (CAD), chronic pain, osteoporosis, incontinence, and weakness
Treatment: Increase in Personal Care Aide to 7 Days per Week, 2-12 Hours per Day (Split Shift) (168 Hours per Week)
The insurer denied the increase in personal care aide to 7 days per week, 2-12 hours per day (split shift), 168 hours per week.
The denial is overturned. 

This patient is a female with cognitive impairment, hypertension (HTN), coronary artery disease (CAD), chronic pain, osteoporosis, incontinence, and weakness.  She is appealing denial of increase in personal care aide (PCA) from seven days a week, 12 hours a day to seven days a week, two-12 hours a day (split shift), 168 hours per week.  The patient was approved for PCA at seven days a week live-in for three months.
 
Assessment performed notes moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, transportation, locomotion, and toilet use; maximal assistance with managing medications, phone use, bathing, personal hygiene, dressing, and walking; extensive assistance with eating; and limited assistance with bed mobility.  The patient is observed to be bedbound.  She is incontinent of bowel and bladder.  Compared to an assessment performed several months prior, the patient has increased from maximal assistance to total dependence with toileting.  This assessment does not note the patient is bedbound.  A letter from the patient's provider states the patient has a rapidly deteriorating mental and physical status.  It states the patient is immobile and confined to the bed.  It states the patient requires bihourly turning and repositioning to prevent bed sores.  It states the patient requires daytime and nighttime diaper changes.  She has repeated falls.  It states the patient needs assistance with activities of daily living (ADLs) as already accounted for in the assessment.

Yes, the proposed increase in personal care aide to seven days per week, two-12 hours per day (split shift), 168 hours per week is medically necessary.  Medically necessary services are those which are safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, and the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

Continuous or split shift personal care service 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 provider five hours daily of uninterrupted sleep during the aide's shift.  Personal assistance services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs), health maintenance activities, and routine support services.  

This patient has multiple chronic conditions and is bedbound.  Assessment performed shows the patient requires assistance with all activities of daily living and personal care needs.  It also notes the patient is bedbound, which is not indicated on the prior assessment.  This assessment also shows deterioration in toileting to total dependence.  The appeal letter from the patient's doctor notes the patient's condition is deteriorating and the patient needs bihourly turning and repositioning.  This patient has continuous needs.  The frequency of care needed would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.  Based on the progression of this patient's condition with limited mobility and bedbound status, the proposed increase in personal care aide from seven days a week, 12 hours a day to seven days a week, two-12 hours a day (split shift), 168 hours per week is medically necessary to meet this patient's needs for assistance as noted above.