Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, major depressive disorder, irritability and anger, gout, and urinary incontinence.
Treatment: Increase in personal care aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift) for a total of 168 hours per week.
The insurer denied coverage for an increase in personal care aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift) for a total of 168 hours per week.
 The denial is overturned.

This case involves a male seeking authorization for coverage for increase in personal care aide services for 12 hours/day, 7 days a week and 12 hours/day 7 days/week split shift for total of 168 hours/week. The patient had a history of urinary incontinence, gout, irritability and anger, depressive disorder, and generalized osteoarthritis. It was noted that the patient was not self-correcting and made poor decisions. The patient required constant supervision due to declining cognition. Reportedly, the patient drank from a detergent bottle and had forgotten to turn off the stove. There were reports of wandering. It was noted that the patient required assistance with activities of daily living as well as bowel and bladder continence secondary to limited range of motion, impaired coordination, pain, forgetfulness, and confusion. Overall, the patient had declined.  

In this case, the documentation reported that the patient had decompensated. The patient was legally blind due to advanced glaucoma. The patient had difficulty in walking and standing for prolonged periods. He had an ataxic gait. He had a history of repeated falls and was high fall risk. The patient also suffered from cognitive impairment related to dementia. The patient had progressive disorientation, psychotic episodes, paranoia, anterograde amnesia, and increased nighttime agitation. Due to the patient's rapid cognitive, physical, and functional decline, the patient required daily supervision and assistance. The patient needed reminders in performing activities of daily living which he could no longer perform independently. He had multiple daily soiled diaper changes. The patient required split shift of 12 hours of home care daily and nightly 7 days/week to maintain his current health and functional capabilities. The patient has severe nighttime agitation. The treating provider felt that split shift 12 hours per 7 days a week was medically necessary for the patient.

This reviewer agrees that based on the documentation, split shift 12 hours/day is medically necessary for the patient. The patient has had a significant decline in physical capabilities as well as cognition. The patient is up frequently throughout the night and is prone to wandering in which a care aide would be unlikely to obtain 5 hours of sleep uninterrupted. The patient requires assistance with
activities of daily living tasks throughout the day as well as night. The patient requires assistance with ambulation and all toileting care needs. The patient also has limited support at home with family that is not available frequently and a spouse that has also been recommended for personal care hours.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for increase in personal care aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift) - a total of 168 hours per week is overturned. Medical necessity is substantiated.