Diagnosis: dementia
Treatment: personal care assistant
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 female with past medical history of atherosclerotic heart disease, atrial fibrillation with chronic anticoagulation, congestive heart failure, end-stage renal disease on hemodialysis, hypertension, hyperlipidemia, aortic insufficiency, gout, hypertension, dementia, anxiety, and depression who had been assigned PCA (personal care assistant) services based on telephonic assessment performed that assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, and shopping while maximum assistance with tasks of managing medication and transportation. With tasks of phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with task of bed mobility. The patient was assessed at independent with task of eating. There was a request to increase PCA services and the patient underwent a telemedicine assessment that assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, and transportation while maximum assistance with tasks of managing medication and phone use. With tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with task of bed mobility. The patient was assessed at supervision only with task of eating.

Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift) are not medically necessary for this patient.
Although there is documentation of worsening cognitive and functional status as well as lack of formal and informal care, there is no documentation that the patient has overnight care needs that would not allow a live-in PCA to obtain 5 hours of uninterrupted sleep. There are no overnight care logs documenting the overnight care needs of the patient. There is no documentation of a need for turning and repositioning every 2 hours. The patient does have unscheduled and unpredictable care needs but again there is no documentation that these care needs would not allow a PCA to obtain less than 5 hours of uninterrupted sleep. 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) are not medically necessary for this patient.