Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced Alzheimer's disease, incontinence, and functional deficit
Treatment: Personal Care Assistance (PCA) services: 2 - 12 hour shifts (24 hours/day), 7 days/week
The health plan denied the requested PCA services: 2 - 12 hour shifts (24 hours/day), 7 days/week.
The health plan's determination is overturned.

The patient is a female with a medical history notable for advanced Alzheimer's disease, incontinence, and functional deficit resulting in being bed bound. The patient is receiving 12 hours/day, 7 days/week (84 hours/week) of level 2 personal care services (PCS). The patient's care team requested an increase to 2 - 12-hour split-shift (24 hours/day, 168 hours/week).

The patient's daughter states that she has been providing care assistance for her mother overnight. However, due to her own health issues, she is no longer able to do so, and is requesting additional coverage to meet her nighttime needs.

The patient's primary care physician states that the patient has advanced dementia, is non-ambulatory, and is bed bound. She requires turning and positioning in bed every 2 hours throughout the day and night. She requires assistance for all activities of daily living (ADLs).

Nighttime caregiver logs were provided for review. They show that in addition to requiring turning and repositioning in bed, the patient had urinary incontinence requiring a diaper change and appropriate hygiene measures every 2-4 hours overnight (occurring 3-4 times per night) and frequently has bowel movements overnight.

Medical records from the treating physician were provided for review, and corroborate the history as detailed above. The patient is at risk for heal and sacral ulceration, but the notes state that the area is currently without evidence of skin breakdown.

A Uniform Assessment System (UAS) was completed and found that the patient is nonverbal with severely impaired cognition She requires total dependence for nearly all instrumental activities of daily living (IADLs). She requires total dependence for nearly all ADLs, with the exception of eating, for which she requires maximal assistance. She is incontinent of both stool and urine. Her functional status was similar to a prior UAS completed. A task tool associated with the most recent UAS recommended 80 hours/week for personal care assistance (PCA).

At issue is the medical necessity of the requested health service/treatment of PCA services: 2 - 12-hour shifts (24 hours/day), 7 days/week, a total of 168 hours/week.

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

The requested health service/treatment of PCA services: 2 - 12-hour shifts (24 hours/day), 7 days/week, a total of 168 hours/week is medically necessary for this patient.

The patient is bed bound and requires total dependence for nearly all IADLs and ADLs. She requires turning and positioning every 2 hours during the day and night. She has episodes of urinary and fecal incontinence every 2-4 hours throughout the day and night. She has clearly demonstrated a medical necessity for split-shift PCS. She cannot go any length of time without a caregiver; if she failed to get diaper changes and repositioning in bed, she could suffer from skin breakdown and/or infection. She has been cared for by her daughter overnight, but her daughter is no longer capable of providing this service. It is therefore medically necessary for the health plan to provide for the patient's personal care needs. The task tool can be helpful as a guideline for PCS, but it is not applicable in a case like this where the patient has unpredictable and periodic personal care needs that occur around the clock.