Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Newly diagnosed ovarian cancer, osteoarthritis, diabetes, asthma, hypertension, and osteoporosis.
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift).

The insurer denied the Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift).  The denial is partially overturned.

This patient is an elderly female, who has medical conditions including newly diagnosed ovarian cancer, osteoarthritis, diabetes, asthma, hypertension, and osteoporosis. She is appealing denial of increase personal care aide (PCA) services for a total amount of 168 hours per week, split shift. The health plan approved 40 hours per week. Uniform Assessment System (UAS) evaluation recently completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, lower body dressing, walking, locomotion, and toilet transfer; extensive assistance with personal hygiene, upper body dressing, toilet use, and bed mobility; limited assistance with managing finances and medications; and independent with eating. She has bowel and bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with managing medications, bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility. Appeal statements note the patient's condition has worsened since her diagnosis of advanced ovarian cancer. Chemotherapy has resulted in diarrhea and fecal incontinence with numerous unexpected trips to the toilet day and night. The patient reports that she lives alone and has cancer, weakness, and difficulty walking. She states she needs assistance with everything. 

An increase in personal care aide (PCA) services for a total amount of 91 hours per week, live in, is medically necessary. However, an increase in personal care aide services for a total amount of 168 hours per week, split shift, 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 aide five hours daily of uninterrupted sleep during the aide's shift. 

This patient has multiple chronic conditions including recently diagnosed ovarian cancer for which she is receiving chemotherapy. She is appealing denial of increase personal care aide (PCA) services for a total amount of 168 hours per week, split shift. The health plan approved 40 hours per week. Uniform Assessment System (UAS) evaluation recently completed shows the patient requires assistance with all activities of daily living (ADLs). The patient is incontinent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with managing medications, bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility. The records and appeal statements note the patient's functional status has declined since being diagnosed with ovarian cancer. She has fecal urgency and incontinence. The information provided shows that this patient has significant limitations in functioning that cannot be met with the approved personal care aide (PCA) 40 hours per week. However, the documentation does not support that the patient has continuous needs that would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. The information supports personal are aide (PCA) 91 hours, live in, as medically necessary for this patient.