Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced Dementia. 
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week. 

The insurer denied: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week. 

The denial is overturned in part. 

The patient is a male with medical history notable for advanced dementia, gait dysfunction (wheelchair bound), coronary disease, peripheral vascular disease, osteoarthritis, and sarcopenia. The patient was approved for 4 hours per day, 5 days per week of personal care services. The patient and his care team requested an increase to 24-hour split-shift services, 168 hours per week. This request was partially approved by the plan, who did authorize an increase to 4 hours per day 7 days per week for a total of 28 hours per week. 

A letter of medical necessity was submitted by the patient's treating physician. The letter states that the patient has urinary and fecal incontinence requiring multiple daily soiled diaper changes. The letter describes his "rapid cognitive, physical, and functional decline" and reports that he needs care assistance with nearly all activities. He suffered a fall with hospitalization and is no longer able to walk, now wheelchair bound. A letter of appeal was submitted by a patient advocate as well. The letter states that he "might not be eligible for split shift" but that he is "wheelchair bound and cannot change his diapers for urinary and fecal incontinence." 

A Uniform Assessment System (UAS) was completed and was available for review. A prior assessment was available for comparison. In the most recent review, the patient was alert and oriented times two (unable to recall date and time). Family reported increasing episodes of confusion at that time. He is unable to express his feelings and has had episodes of wandering. From a functional standpoint, he requires total dependence for meal preparation, housework, and finances. He requires maximal assistance for managing medications. He requires maximal assistance for bathing and dressing lower body. He requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, toilet use, and bed mobility. He is frequently incontinent of urine, and continent of stool per the assessment. He uses pull ups, however due to his dementia he has frequently been taking them off and urinating through his pants. Compared with the prior assessment from prior to that, there was a decline in functioning across numerous activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). 

The requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is not medically necessary for this patient; however, the patient has a medical necessity for 24 hour (live-in) personal care. 

The patient's physical, functional, and cognitive status have declined significantly in the recent months. His hospitalization last month resulted in him being wheelchair bound. He is incontinent (of urine) and has dementia, unable to always make his care needs known. He can use incontinence supplies but will need personal care throughout the day and night to manage the incontinence products. He does not have any specific needs that would warrant split-shift care, and it would be reasonable to expect a personal care aide to go a minimum of 5 hours overnight without the need for personal care services. The original determination made by the health plan was based on a UAS performed prior to his hospitalization and was based on outdated information on his personal care needs.