Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week. 

The health plan denied: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week. 

The determination is overturned. 

The patient is a female with medical history notable for dementia. The patient is approved for 9 hours per day, 7 days per week (63 hours per week) of level 2 personal care aide (PCA) services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week) and this request was denied by the health plan. This denial is the subject under review. 
The patient is currently residing in a nursing and rehabilitation facility after she suffered a fall at home while unsupervised. The physician who is caring for her there provided a letter of support for this appeal. The letter states that the patient is at "risk of falls if not monitored" and that she often tries to go to the bathroom by herself and ends up falling. The physician states that in their opinion "she needs 24-hour care." 
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted at the rehab facility with the patient's daughter present. She normally lives alone in an apartment. Her cognition is severely impaired; she is able to state her name but is confused and disoriented most of the time. She requires total dependence for all Instrumental activities of daily living (IADL). For her activities of daily living (ADL), she requires total dependence for walking, locomotion, and toilet use. She requires maximal assistance for all others. She is incontinent of stool and urine with no control present. 

At issue is the medical necessity of the requested health service/treatment of PCA Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week. 

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

The requested health service/treatment of PCA Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week is medically necessary for this patient. 

The patient has advanced dementia and is unable to direct her own care. She is incontinent of stool and urine with no control present. Her personal care needs are expected to be continuous and unscheduled in nature, and she will need care throughout the day and night. She cannot be left in a soiled diaper overnight as this could lead to skin breakdown and/or infection. Therefore, 24-hour split-shift care is medically necessary to meet her personal care needs. 

Of note is that the plan denied this request due to lack of a safe discharge plan for medication oversight. The patient does not have any informal help in the home from family. The plan is correct that it is not within the scope of practice of a personal care aide to manage medications. Therefore, it is also true that this aspect will need to be addressed as part of safe discharge planning.