Diagnosis: Cognitive impairment
Treatment: Personal Care Assistant services 7 days x 24 hours (continuous services)
The insurer denied the Personal Care Assistant services 7 days x 24 hours (continuous services).
The denial is upheld.

The patient is a female with medical conditions including Alzheimer's disease, HTN (hypertension), depression, MS (multiple sclerosis), CVA (cerebrovascular accident), insomnia, and CTS (carpal tunnel syndrome). This is a request for approval from live-in to continuous PCA (personal care assistant) services. Additional care is requested to managed toileting needs at night.

Provider notes that the patient is at high risk for falls due to unsteady gait and cognitive impairment. She is in rehab and requesting to return home. Assessment performed shows the patient has severe cognitive impairment; total dependence with meal preparation, shopping, housework, managing finances, bed mobility, and toileting; extensive assistance with managing medications; maximal assistance with phone use, transportation, bathing, dressing, and personal hygiene; uses wheelchair and scooter or locomotion; and frequently incontinence of bowel and bladder.

No, the Personal Care Assistant services 7 days x 24 hours (continuous services) are not medically necessary.

Medically necessary services are typically which are:
- safe
- effective
- generally accepted national standard of medical practice
- not provided primarily for convenience of the patient or the practitioner
- the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested increase in services from live-in to continuous PCA (personal care assistant) is not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

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 provide obtain routine five hours daily of uninterrupted sleep during the aide's eight-hour period of sleep. The assessment does not support the medical necessity for continuous Personal Assistance Service. The continuous care was requested to assist with toileting/diapering at nighttime. This is not a medical condition for which continuous care is indicated. The approved live-in PCA (personal care assistant) is sufficient to provide assistance with ADLs (activities of daily living) and personal care for this patient's scenario.