Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) 2 12 hours split shift per day, 7 days a week 
The insurer denied: Personal Care Aide (PCA) 2 12 hours split shift per day, 7 days a week 
The denial is partially overturned.

The patient is a female with medical history notable for Parkinson's disease, dementia, incontinence, recent hospitalization from a fall, and spinal stenosis. The patient is currently approved for 12 hours per day, 7 days per week (84 hours per week) of personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 split-shift), 7 days per week (168 hours per week), and this request was denied by the insurance company. This denial is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented to person and place only and was very forgetful. Recall is two out of five at five minutes. Procedural memory intact. General Practitioner Assessment of Cognition (GPCOG) screening was 3/9, consistent with cognitive impairment. From a functional standpoint, she requires total dependence for meal preparation, housework, shopping, and transportation. She requires extensive assistance for managing medications. For her activities of daily living (ADLs), she requires maximal assistance for bathing, locomotion, toilet transfer, and toilet use. She requires extensive assistance for dressing lower body. She requires limited assistance for hygiene, dressing upper body, and bed mobility. She is "very weak and drowsy... unable to stand up or walk without physical assistance... requires ADLs/Instrumental activities of daily living (IADLs) assistance due to severe weakness, poor balance, dizziness, difficulty in walking, bending down, and standing." The patient does not have any informal help. She is frequently incontinent of urine and is continent of stool. Compared to prior assessment, she showed a decline in functional status.

The health plan's determination is overturned in part. 

The requested health service of PCA 2 12 hours split shift per day, 7 days a week medically necessary for this patient is not clearly demonstrated to be medically necessary for this patient.

The patient has had a functional decline and requires assistance with all ADL's and IADL's. This is complicated by her dementia and urinary incontinence. The patient cannot schedule all of her personal care needs during a PCA shift. If she soils a pull up overnight, she is not capable of changing it on her own. It is not reasonable to expect that she would not have any toileting needs for 12 hours. Failure to provide for her toileting needs could lead to skin breakdown and/or infection. It is medically necessary for her to have an aide present in the night.

There is no documented medical necessity for split-shift care. The patient does not have evidence of personal care needs that would preclude an aide from routinely getting 5 hours of sleep per night. She does not have any pressure ulcers that require manual turning and positioning. While 2 12 hour split shift services (168 hours per week) are not medically necessary, the patient's needs could be met by one 24 hour live in personal care aide; medical necessity for this is established.