Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unstable gait.
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days (s) per week - a total of 168 hours per week (split shift).
The insurer denied Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - a total of 168 hours per week (split shift).
The determination is overturned in part.

This is a male patient with a medical history notable for incontinence, unstable gait, and weakness. The patient is approved for 12 hours per day, 7 days per week (a total of 84 hours per week) of personal care assistance. The patient and his care team requested an increase to 24 hours per day (212-hour split-shift), 7 days per week (total of 168 hours per week), and the request was denied by the health plan.
The patient's healthcare proxy provided a letter for this appeal. The letter states that the patient cannot ambulate, transfer, or toilet without assistance. He also has urinary incontinence. His wife has advanced cancer and is no longer able to provide informal support at night.
A Uniform Assessment System (UAS) was completed. The assessment was conducted in person. The patient was alert and oriented with short-term memory problems and intermittent confusion. His mini-mental state examination (MMSE) score was 18/30, consistent with moderate cognitive impairment. He requires maximal assistance or total dependence for all instrumental activities of daily living (IADLs). For his activities of daily living (ADLs), he requires total dependence for dressing, locomotion, and toilet use. He requires maximal assistance from all others. He requires significant weight-bearing human physical support with walking. He cannot use a walker due to upper extremity weakness. He is frequently incontinent of urine and stool. There was no pressure ulcer present. At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - a total of 168 hours per week (split shift).

The services are medically necessary in part. The requested health service of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - a total of 168 hours per week (split shift) has not been demonstrated to be medically necessary for this patient. 24-hour per day live-in personal care aide; 7 days per week for a total of 91 hours per week is medically necessary for this patient.
The patient requires personal care aide assistance for all activities of daily living. He is incontinent and cannot manage his incontinence care products but can direct his care. His personal care needs are expected to be continuous and unscheduled throughout the day and occasionally at night as well. His wife has been providing informal assistance but is no longer able to do so due to her own medical condition. Therefore, 24-hour live-in personal care is medically necessary.
There is insufficient evidence that 24-hour split-shift care is medically necessary. The patient does not have any pressure ulcer that requires periodic turning and repositioning throughout the night. There is no physician statement regarding the frequency of needs overnight. There are no care logs demonstrating that a live-in care aide would not be able to receive sufficient rest at night. Therefore, the request for 24-hour split-shift care has not been demonstrated to be medically necessary for the patient.
The health plan's determination of medical necessity is overturned in part. 24-hour per day live-in personal care aide, 7 days per week for a total of 91 hours per week is medically necessary for this patient.