Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia behavioral disturbance, hallucinations, incontinence, osteoporosis and osteoarthritis
Treatment: Increase Personal Care Assistant (PCA) Services To 7 Days x 24 Hours Per Day (split shift), Pre-service
The insurer denied the increase personal care assistant (PCA) services to 7 days x 24 hours per day (split shift), pre-service.
The denial is upheld.

The patient is a female. Her conditions include dementia behavioral disturbance, hallucinations, incontinence, osteoporosis and osteoarthritis. The patient lives alone. She is appealing denial of an increase in Personal Care Assistant (PCA) services to 7 days x 24 hours per day, split shift. She was approved for 7 days x 24 hours per day, live in.

UAS (Uniform Assessment System) evaluation performed showed the patient ambulating and transferring independently. Notes indicated that an increase in hours was requested for supervision due to wandering and unsafe behavior.

A letter from the provider notes the patient's condition is deteriorating and has progressed over the past six months. They note that the patient had a fall approximately a month after assessment. They note that the patient is ADL (activities of daily living)-dependent and requires maximal assistance with transferring and ambulation. Her informal caregivers are unable to provide the extent of support she needs. They note that the patient requires medications around the clock.

An appeal letter from a provider notes that the patient is status post a fall. She has a decline in her ADLs (activities of daily living) and worsening of gait disorder.

No, the requested increase in personal care assistant (PCA) services to 7 days x 24 hours per day (split shift) is not medically necessary.

The requested health service is not medically necessary because it is not consistent with standard of care.

Personal care service is necessary when assistance cannot be met from 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 provider five hours daily of uninterrupted sleep during the aide's shift.

This patient has multiple chronic conditions, including dementia. She lives alone. She is appealing denial of an increase in Personal Care Assistant (PCA) services to 7 days x 24 hours per day, split shift. She was approved for 7 days x 24 hours per day, live in. An increase in hours was requested for supervision due to wandering and unsafe behavior. UAS (Uniform Assessment System) evaluation performed showed the patient ambulating and transferring independently. However, appeal letters indicate that the patient has a deteriorating mental and physical functioning and requires maximal assistance with transferring and ambulation. They note that gait disorder places the patient at fall risk. She is status post a fall approximately a month after assessment. The information provided does not support that his patient has continuous needs of a PCA (personal care assistant). PCA is not indicated for supervision or when no tasks are being performed. The approved 7 days x 24 hours per day, live in is appropriate. The proposed PCA 7 days x 24 hours per day, split shift, is not medically necessary.