Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease; osteoarthritis.
Treatment: Increase Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift).
The insurer denied the Increase Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift).
The denial is overturned.

The patient is a male. His medical conditions include Parkinson's disease, dementia, diabetes, osteoarthritis, and heart disease. Denial of increase personal care aide (PCA) services for a total of 168 hours per week, split shift, is being appealed. The plan has approved PCA (personal care aide) live-in services.

The patient's Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total assistance with housework and locomotion; maximal assistance with meal preparation, managing finances and medications, shopping, bathing, personal hygiene, dressing, walking, toileting, and bed mobility; extensive assistance with eating; and limited assistance with phone use. He has a Foley catheter due to urinary retention. He has infrequent bowel incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with walking, locomotion, bed mobility and eating.

There is an appeal letter from the patient's provider that notes that the patient has been admitted to hospice within the last several months. The patient is bedbound. He is noted to be more disoriented. He is not able to reposition himself, which places him at risk for skin breakdown. He requires full assistance with all ADLs (activities of daily living). He needs repositioning every two hours while in bed. He has unscheduled needs throughout the nighttime.

Yes, the requested increase in Personal Care Aide services to 24 hours/day, 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.
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. He is appealing denial of increase PCA (Personal Care Aide) services for a total of 168 hours per week, split shift. The plan has approved PCA (Personal Care Aide) live-in services.

The patient has advanced Parkinson's disease with dementia. He is in hospice care. UAS (Uniform Assessment System) evaluation completed shows the patient needs assistance with all ADLs (activities of daily living) and personal care. Compared to UAS (Uniform Assessment System) evaluation completed o previously, there has been a decline in functional status with walking, locomotion, bed mobility and eating. The appeal letter notes the patient is bedbound and requires assistance with all ADLs (activities of daily living) and personal care as well as repositioning every 2 hours. This patient has significant physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. He requires total care and frequent repositioning. These needs do not permit five hours daily of uninterrupted sleep during the aide's shift. The approved PCA (Personal Care Aide), live-in, is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living)/IADLs (instrumental activities of daily living). The requested increase in PCA (Personal Care Aide) for a total of 168 hours per week, split shift is medically necessary.