Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic cough, polyarthritis, diabetes. 
Treatment: Increase Personal Care Aide (PCA) Services to 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: Increase Personal Care Aide (PCA) Services to 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 elderly male has multiple chronic medical conditions. He lives alone. The denial of an increase in personal care aide (PCA) services for 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 is being appealed. The health plan approved live-in services. The Uniform Assessment Systems (UAS) evaluation completed five months ago shows moderately impaired cognition and functional status requires maximal to total dependence with all activities of daily living (ADLs). He has bladder and bowel incontinence. Compared to Uniform Assessment System completed last year, there has been a decline with dressing, toilet use, bathing, locomotion, and eating. A letter from the patient's child indicates the patient has deteriorated since evaluation was performed five months ago and requires total assistance care. The child is unable to assist at night and notes the aides are unable to get five hours of uninterrupted sleep. Nighttime logs have been provided showing frequent nighttime assistance with toileting. A letter from the patient's provider notes the patient has multiple chronic conditions and requires total assistance with activities of daily living. He needs assistance during nighttime to clear sputum related to chronic cough and dysphagia as well as toileting. He needs to be turned and repositioned every two hours. 

The proposed treatment is 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 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. This patient has multiple chronic conditions. The denial of an increase in personal care aide (PCA) services to 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 is being appealed. The health plan approved live-in services. Uniform Assessment Systems (UAS) evaluation completed five months ago shows the patient requires maximal to total dependence with all activities of daily living. The patient has bladder and bowel incontinence. Compared to Uniform Assessment System completed last year, there has been a decline with dressing, toilet use, bathing, locomotion, and eating. The appeal statements and nighttime logs support the patient is dependent with all activities of daily living and requires frequent assistance with toileting and turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed personal care aide services for a total of 168 hours per week, split shift, is medically necessary.