Diagnosis: Dementia.
Treatment: Home health care./ Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift).
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift).
The health plan's determination is upheld.

The patient is a male with past medical history of Parkinson's, dementia, urinary incontinence, hyperlipidemia, benign prostatic hyperplasia (BPH), depression, diabetes mellitus type II, congestive heart failure (CHF), deep vein thrombosis (DVT), gastroesophageal reflux disease (GERD), osteoarthritis, history of sacral ulcer, macular degeneration, bladder cancer, and orthostatic hypotension who had been assigned PCA (personal care assistant) services 42 hours/week based on assessment performed assessing the patient at total assistance with task of managing finances while maximum assistance with tasks of meal preparation, ordinary housework, managing medication, shopping, and transportation. With tasks of phone use and stairs, the patient was assessed at extensive assistance while limited assistance with tasks of bathing, personal hygiene, walking, locomotion, transfer toilet, and toilet use. The patient was assessed as supervision with task of eating and independent with task of bed mobility.

Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift) is not medically necessary for this patient.
There is documentation of increased care needs when comparing the recent assessments as well as documentation of multiple hospitalizations in previous year with subsequent rehabilitation stay. The plan appropriately increased PCA services from 42 hours a week to 24 hours/day, live-in, 7 days/week following latest assessment. The documentation provided does not support the need for PCA services 24 hours/day, split-shift, 7 days/week as there is no documentation of overnight care needs. There is also no documentation of the need for turning and repositioning at least every 2 hours. In addition, there is no documentation of care needs that would not allow a PCA 5 hours of uninterrupted sleep. PCA services are not provided for safety and supervision or when tasks are not being performed. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift) is not medically necessary for this patient.