Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral vascular disease, and she is status post right transmetatarsal amputation, history of syncope. 
Treatment: Personal Care Assistance Services, 24 Hours Per Day, 7 Days per Week (split shift). 

The insurer denied the Personal Care Assistance Services, 24 Hours Per Day, 7 Days per Week (split shift). 

The denial is overturned, in part. 

The patient is a female. Her conditions include peripheral vascular disease, and she is status post right transmetatarsal amputation. She also has history of syncope.  She lives alone.  Denial of increase personal care assistance (PCA) services, 24 hours per day, 7 days per week, split shift, is being appealed. The health plan approved increase from 49 hours per week to 52 hours per week. 

The patient's provider states the patient needs 24/7 assistance with all ADLs (activities of daily living) due to frequent falls and syncope.  She had orthostatic hypotension in the hospital. Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, stairs, shopping, and transportation; extensive assistance with managing finances and medications, bathing, lower body dressing, locomotion, toileting, and bed mobility; limited assistance with personal hygiene upper body dressing; and supervision with eating.  She has bowel and bladder incontinence.  She was hospitalized after a fall. 

Yes, in part. The requested Personal Care Assistance Services, 24 Hours Per Day, 7 Days per Week (split shift) is medically necessary, in part. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part. 

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. Denial of increase in PCA (personal care assistance) services, 24 hours per day, 7 days per week, split shift, is being appealed. The health plan approved increase from 49 hours per week to 52 hours per week. 

This patient has multiple chronic medical conditions. She had recent hospitalization after a fall at home and is status post partial foot amputation. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living), except eating. She has bladder and bowel incontinence. The provider notes she needs assistance with all ADLs (activities of daily living). This patient has significant physical impairments that require assistance with ADLs (activities of daily living). The approved PCA (personal care assistance) 52 hours per week is inadequate to meet the patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). However, the requested PCA (personal care assistance) services, 24 hours per day, 7 days per week, split shift is not medically necessary, because the information does not support that the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. PCA (personal care assistance) services, 24 hours per day, 7 days per week, live-in, is appropriate for this patient.