Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, heart disease, osteoporosis, arthritis, and history roof hip fracture
Treatment: Increase Personal Care Aide (PCA) Services to 24 Hours Per Day (split shift), 7 Days Per Week, For A Total Of 168 Hours Per Week
The insurer denied the Increase Personal Care Aide (PCA) Services to 24 Hours Per Day (split shift), 7 Days Per Week, For A Total Of 168 Hours Per Week
The denial is overturned, in part. 

The patient is a female. Her conditions include dementia, heart disease, osteoporosis, arthritis, and history roof hip fracture.  She lives alone.  Her nephew assists with meal preparation.  The patient was hospitalized earlier in the year after a fall.  She is incontinent of bowel and bladder.

UAS (Uniform Assessment System) evaluation completed in the spring shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, stairs, shopping, and locomotion; maximal assistance with managing medications, phone use, transportation, bathing, lower body dressing, and toileting; extensive assistance with upper body dressing; limiter assistance with earring; and independent with bed mobility; and limited assistance with personal hygiene. The patient's physical activity is less than one hour.  Compared to UAS (Uniform Assessment System) evaluation completed previously, the patient shows decline in dressing, toilet use, bathing, walking, locomotion, and eating.  Her DME (durable medical equipment) includes Motorized Wheelchair/Scooter, Personal Emergency Response System (PERS), Shower Chair, Shower Grab Bar, Wheelchair, and adjustable bed.

Appeal statement notes the patient requires assistance with all ADLs (activities of daily living). It notes that the patient's functional capacity has declined since her fall. It notes that the patient is bedbound. It further notes that the patient needs significant assistance with weight bearing to transfer out of bed.  As a result, she goes without assistance in transferring and using the bathroom for 18 hours per day.

A letter from the patient's provider states that the patient's functioning has decreased.  She has had mechanical falls. The letter notes that the patient requires assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation.  The patient is bed-bound for 8 to 12 hours when her attendant leaves.

Yes, in part. The Increase in Personal Care Aide (PCA) Services to 24 Hours Per Day (split shift), 7 Days Per Week For A Total Of 168 Hours Per Week is medically necessary, in part. Specifically, the increase in personal care aide services to 24 hours per day (live-in) is medically necessary.
Medically necessary services are those which are:
safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, and the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

An increase in personal care aide services to 24 hours per day (live-in) is medically necessary, because it is consistent with generally accepted national standard of medical practice.

Personal Care Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient has multiple chronic conditions, including dementia.  The appeal is regarding denial of 24 hours per day, split shift personal care aide service.  She was approved for 42 hours per week.

The patient lives alone.  She was hospitalized after a fall and is noted to have a decline in functioning since hospitalization.  UAS (uniform assessment system) evaluation performed shows the patient requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living) except bed mobility.  Compared to UAS (Uniform Assessment System) evaluation completed previously, the patient shows decline in dressing, toilet use, bathing, walking, locomotion, and eating.  The appeal letters show that the patient's functional status is deteriorating.  The patient is bed-bound.  She has bowel and bladder incontinence.  This patient has continuous needs that cannot be met with the approved personal care aide services 42 hours per week.

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 documentation does not support the need for personal care aide 24 hours per day, split-shift, because there is inadequate evidence of the patient with needs, such as repositioning or turning that would prohibit the aid from obtaining five hours daily of uninterrupted sleep.

In conclusion, while the requested increase in personal care aide services to 24 hours per day, split-shift, is not appropriate, an increase in personal care aide services to 24 hours per day, live-in, is medically necessary to meets this patient's needs for assistance with ADLs (activities of daily living) and personal care.