Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Weakness and impaired cognition.
Treatment: Increase Personal Care Aide (PCA) Services to 24 hours per day (in two - 12 hours), (split shift) seven days per week for a total of 168 hours per week.
The insurer denied the requested Personal Care Aide (PCA) Services to 24 hours per day (in two - 12 hour shifts, split shift) seven days per week for a total of 168 hours per week.
The denial is overturned, in part.

The patient is a senior male.  He has several chronic medical conditions. The patient's UAS (Uniform Assessment System) evaluation shows minimally impaired cognition and functional status, with total dependence with meal preparation, housework, and shopping.  He requires maximal assistance with managing medications, bathing, with extensive assistance with managing finances, personal hygiene, dressing, walking, locomotion, toileting, bed mobility, and supervision with eating.  His condition has deteriorated due to progressive weakness, limited ROM (range of motion) and impaired cognition. The patient reports a hard time repositioning himself due to pain and weakness. He is frequently incontinent of urine.  The patient had a fall when he was trying to get out of bed without assistance.  He had a fall again when he  lost balance while using rollator.  He also fell out of bed one day.  Compared to UAS (Uniform Assessment System) evaluation , there has been a decline in functional status with meal preparation, bathing, personal hygiene, walking, locomotion, and bed mobility.

The statement from the home healthcare agency notes that the patient has steady decline with cognition.  The home healthcare agency notes that the patient is totally dependent with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation.  The home healthcare agency recommended PCA (personal care aide) 24 hours per day, split shift.

A letter from the patient's provider states the patient has poor mobility and is wheelchair bound. The provider notes that the patient has multiple falls. The provider recommended constant help due to frequent nighttime awakenings for toileting and risk for nighttime falls. A log provided in the records shows that the patient needs assistance with urinary incontinence at varying hours, and that the patient complains of inability to sleep and that the patient has concerns with his portable oxygen.

This patient has multiple chronic medical conditions.  This is an appeal of denial of the request for Personal Care Aide (PCA) Services to 24 hours per day (in two - 12 hour shifts, split shift) seven days per week for a total of 168 hours per week.  His insurer had approved for partial increase in PCA (personal care aide) from 35 to 42 hours per week.

Yes, an increase in personal care aide (PCA) services to 24 hours per day, live in, is medically necessary, in part.  The increase in requested Personal Care Aide (PCA) Services to 24 hours per day (in two - 12 hour shifts, split shift) seven days per week for a total of 168 hours per week) is not 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 provider five hours daily of uninterrupted sleep during the aide's shift. 

The patient's UAS (Uniform Assessment System) evaluation shows the patient requires assistance with all ADLs / IADLs (activities of daily living / instrumental activities of daily living), except eating.  Compared to the UAS (Uniform Assessment System) evaluation, there has been a decline in functional status with meal preparation, bathing, personal hygiene, walking, locomotion, and bed mobility.  The patient has urine incontinence. He has had multiple falls due to weakness and gait impairment. Appeal statements note the patient is wheelchair-bound and needs nighttime assistance due to urinary incontinence and fall risk.  Logs provided show infrequent awakening for incontinence.  The patient frequently complains of inability to sleep and has anxiety related to oxygen/CPAP (continuous positive airway pressure). This patient has both daytime and nighttime needs for assistance with ADLs / IADLs (activities of daily living / instrumental activities of daily living). The patient's needs cannot be met with the approved PCA (personal care aide) 42 hours per week.  The requested increase in PCA (personal care aide) to a 24 hours per day, split shift, is also not appropriate, because the records do not support the patient has needs with ADLs (activities of daily living) that require continuous care.  PCA (personal care aide) services are not indicated for supervision, such as monitoring due to inability to sleep.  As such, an increase in PCA (personal care aide) services to 24 hours per day, live in, is appropriate and medically necessary.