Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, diabetes, end stage renal disease.
Treatment: Increase Personal Care Aide (PCA) Services for a Total of 168 Hours per Week (Split Shift).
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total of 168 Hours per Week (Split Shift).
The denial is partially overturned.

This elderly female patient has condition including osteoarthritis, hypertension, diabetes, spinal stenosis, end stage renal disease, anemia, and is status post heart attack 2 months ago. The denial of an increase in personal care aide (PCA) services for a total of 168 hours per week (split shift) is being appealed. The health plan approved 49 hours per week.

Uniform Assessment System (UAS) evaluation completed 2 months ago shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances and medications, phone use, shopping, bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility; and limited assistance with eating. The patient has frequent bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed 4 months ago, there has been a decline with managing finances, personal hygiene, upper body dressing, toileting, and bed mobility. A letter from the Social Worker notes the patient is wheelchair bound and has multiple conditions. A letter from the patient's physician notes the patient has several chronic conditions and needs a walker/wheelchair.

The proposed increase in personal care aide (PCA) services for a total of 168 hours per week (split shift) is not medically necessary; however, an increase to live-in personal care aide services 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. The denial of an increase in personal care aide (PCA) services for a total of 168 hours per week (split shift) is being appealed. The health plan approved 49 hours per week. Uniform Assessment System (UAS) evaluation completed from 2 months ago shows the patient needs a minimum of maximal assistance with all activities of daily living (ADLs), except limited assistance with eating. She has frequent bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed 5 months ago there has been a decline with managing finances, personal hygiene, upper body dressing, toileting, and bed mobility. Appeal statements support multiple chronic conditions and indicate that the patient is wheelchair bound. The information shows that the patient has significant impairments but does not support that she has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved personal care aide services of 49 hours per week is insufficient to meet this patient's needs. However, the proposed increase to 168 hours per week (split shift) is not medically necessary. An increase to personal care aide live-in services is medically necessary for this patient.