Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack
Treatment: increase in PCA hours to 7 days per week, 24 hours (hrs) per day - split shift.
The insurer denied increase in PCA hours to 7 days per week, 24 hours (hrs) per day - split shift.
The determination is upheld.

The patient is a female with past medical history of transient ischemic attack (TIA), chronic insomnia secondary to pain, coronary artery disease, dementia, bladder incontinence, bowel incontinence, hypertension, hyperlipidemia, chronic anticoagulation, seizure disorder, diabetes mellitus, congestive heart failure, gastroesophageal reflux disease (GERD), anxiety, and depression who had been assigned personal care assistant (PCA) services 12 hours per day (hours/day), 7 days/week to total 84 hours/week based video assessment.
There was a request to increase PCA services and the patient underwent a video assessment. It noted the patient had severely impaired cognitive skills and had a decline in decision-making capacity. In addition, notes stated the daughter and son were her main informal caregivers and they both work during the day and were taking turns caring for the patient and spouse in the overnight hours.
The insurer sent an initial adverse determination notice denying the request to increase PCA services stating the patient's current services meet her needs and the information provided showed the patient's care needs could be met with other means.The patient's primary care physician (or provider) (PCP) sent a letter requesting an urgent increase in hours of home care for the patient due to her rapidly deteriorating mental state. The provider noted the patient's medical conditions and the patient had urinary incontinence and required multiple daytime and nighttime changes of soiled diapers and linens as to prevent skin irritation and rash. In addition, the provider noted the patient required continuous supervision and assistance and recommended and believed it was very important and medically necessary for the patient to have split-shifts of 12 hours of home care daily and nightly times (x) 7 days per week to maintain the patient's current health and prevent her illness from progressing.
Tthe insurer sent a final adverse determination denial notice continuing to deny request to increase PCA services noting regulations state that 24 hours/day split shift services are covered with the provision of uninterrupted care, by more than 1 personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning or positioning. The patient should also need assistance with such frequency that a live in, 24-hour personal care aide would be unlikely to obtain, on a regular basis, 5 hours of uninterrupted sleep during the aids 8-hour period of sleep. At issue is the medical necessity of increase in PCA hours to 7 days per week, 24 hours (hrs) per day - split shift.
The services are not medically necessary.
There is no documentation of the medical necessity of split shift services, specifically, the need for turning and repositioning every 2 hours or specific care needs in the overnight hours that would not allow a live-in aide 5 hours of uninterrupted sleep. There were no overnight care logs documenting care needs in the overnight hours that would not allow a PCA 5 hours of uninterrupted sleep. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, are not medically necessary for this patient.