Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip fracture, hypertension, diabetes, osteoporosis, and dementia
Treatment: Personal Care Aide 7 Days for 24 Hours Split Shift
The insurer denied: Personal Care Aide 7 Days for 24 Hours Split Shift
The denial is overturned

This elderly female has conditions including a hip fracture, hypertension, diabetes, osteoporosis, and dementia. She is appealing denial of personal care aide (PCA) seven days for 24 hours, split shift. The health plan approved personal care aide five days for 20 hours and two days for 21 hours, total 142 hours per week. Uniform Assessment System (UAS) evaluation completed earlier last year showed minimally impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, phone use shopping, transportation, locomotion, and toilet use; maximal assistance with bathing, personal hygiene, dressing, toilet transfer, and bed mobility; and supervision with eating. She is wheelchair bound. She has frequent bowel and bladder incontinence. A letter from the patient's doctor notes the patient has declined in dementia and has become immobile. She is confined to a wheelchair. Her daughter will be unable to provide care due to her upcoming knee surgery. A letter from a different doctor notes the patient has urge incontinence and acute cystitis. She needs to urinate every two hours and is unable to make it to the restroom alone. A letter from New York State notes the patient has multiple diagnoses and needs 24-hour care. The patient's family is no longer able to provide overnight care.

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. She is wheelchair bound. She is appealing denial of personal care aide (PCA) seven days for 24 hours, split shift. The health plan approved personal care aide five days for 20 hours and two days for 21 hours, for a total of 142 hours per week. Uniform Assessment System (UAS) evaluation completed earlier last year showed minimally impaired cognition. The patient requires maximal assistance to total dependence with all activities of daily living, except eating. She has frequent bowel and bladder incontinence. The appeal statements support the patient's condition is deteriorating and she is immobile. Her urinary condition results in her need to urinate every two hours. She is losing the informal support of her family for overnight care. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved personal care aide five days for 20 hours and two days for 21 hours, for a total of 142 hours per week, is inadequate to meet the patient's needs for assistance with activities of daily living (ADLs). The personal care aide seven days for 24 hours, split shift, is medically necessary.