Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase personal Care Aide (PCA) Services to 
Split-Shift for a Total of 168 Hours per Week
The insurer denied: Increase personal Care Aide (PCA) Services to Split-Shift for a Total of 168 Hours per Week
The denial is partially overturned

This elderly female with dementia is appealing the denial of an increase in personal care aide (PCA) services to split shift for a total of 168 hours per week. The health plan approved ten hours per day for a total of 70 hours per week. The patient is status post recent T5-T6 (thoracic five to thoracic six) vertebral fracture and hip fracture.
Uniform Assessment System (UAS) evaluation performed recently shows the patient is moderately impaired and functional status: total dependence with meal preparation, housework, managing medications, shopping, bathing, lower body dressing, walking, locomotion, toileting, and bed mobility; maximal assistance with personal hygiene, upper body dressing, and eating; and extensive assistance with phone use. She has bowel and bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation performed 5 months earlier, there has been a decline in functioning with lower body dressing, toileting, bathing walking, locomotion, eating, and bed mobility.
A letter from the patient's child notes the patient has physical and cognitive decline. She cannot be left without supervision. She has had numerous falls and needs help with transfers. 
A letter from a Provider notes the patient has had a progressive decline in ability to manage activities of daily living (ADLs). She had a recent hip fracture. She is in late-stage dementia and needs around-the-clock care. Overnight logs show the patient being assisted with diaper changes and turning in the bed. There is one entry for these in each of the nightly logs.

The proposed increase in personal care aide (PCA) services to split shift for a total of 168 hours per week is not medically necessary; however, an increase in personal care aide to 24 hours per day, live in, 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, including late-stage dementia. She is status post recent hip and vertebral fracture. She is appealing denial of increase personal care aide (PCA) services to split shift for a total of 168 hours per week. The health plan approved ten hours per day for a total of 70 hours per week. Uniform Assessment System (UAS) evaluation performed recently shows the patient requires maximal assistance to total dependence with all activities of daily living (ADLs), except extensive assistance with phone. She is incontinent of 
bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation performed 5 months earlier, there has been a decline in functioning with lower body dressing, toileting, bathing walking, locomotion, eating, and bed mobility. Appeal statement indicate the patient's physical and cognitive functioning have declined. She a history of frequent falls. She requires diaper change and turning at least once per night. The information provided shows that this patient has significant limitations in functioning. The assistance needed with activities of daily living, 
including nighttime, cannot be met with the approved personal care aide (PCA) 70 hours per week. However, the records do not support the necessity for continuous care that would prevent an aide from getting five hours daily of uninterrupted sleep during the aide's shift. The proposed increase to split shift for a total of 168 hours per week is not medically necessary. Personal Care Aide services 24 hours per day, live in, is medically necessary.