Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, hypertension, heart failure, kidney disease, and osteoarthritis. 
Treatment: Personal Care Aide For 168 Hours Per Week (12 hours x 2 x7 days split shift). 

The insurer denied: Personal Care Aide For 168 Hours Per Week (12 hours x 2 x7 days split shift). 

The denial is upheld. 

This patient is an elderly male with medical conditions that include dementia, hypertension, heart failure, kidney disease, and osteoarthritis. Denial of increase personal care aide for 168 hours per week, split shift, is being appealed. The health plan approved 24 hour per day, live in services. The patient's Uniform Assessment System evaluation completed 4 months ago shows moderately impaired cognition and functional status: total dependence with housework; maximal assistance with 
meal preparation, shopping, and lower body dressing; extensive assistance with managing finances and medications, phone use, personal hygiene, upper body dressing, walking, locomotion, and toileting; limited assistance with eating; and independent with bed mobility. He has bowel and bladder incontinence. Letters from the patient's family note that the patient has limited mobility and needs assistance with activities of daily living (ADLs). It is noted the patient has a complex medical history. His health is deteriorating. He gets up at night to urinate and snack. He has a history of frequent falls. He experiences psychotic ideation and phobia at night. He is not safe to be by himself at night. He requires around-the-clock care and supervision. A letter from the patient's provider notes the patient's dementia has been deteriorating. The patient needs assistance with activities of daily living. He is not safe to be left alone due to memory deterioration. He has had several falls recently. He has paranoid delusional ideation that affects his safety. A letter from another provider notes the patient has limited ambulation and uses a walker or wheelchair. He lives alone and will benefit from an increase in care. 

The proposed treatment is not 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 who 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 for 168 hours per week, split shift, is being appealed. The health plan approved 24 hour per day, live in services. This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed 4 months ago shows the patient requires assistance with all activities of daily living (ADLs), except bed mobility. The appeal statements support that the patient requires assistance with all activities of daily living. He has recent falls. His cognitive status is deteriorating, and he experiences psychosis at nighttime. Additional care is recommended for supervision and safety. The 
information provided does not support continuous needs with toileting, transfers, or repositioning/turning that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. Personal care aide services are not indicated for safety supervision or when no tasks are being performed. The requested increase personal care aide for 168 hours per week, split shift, is not medically necessary.