Diagnosis: Hypertension, thyroid disease and dementia, and decubitus ulcers.
Treatment: Personal care aide (PCA) level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week.
The insurer denied coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week.
The denial is overturned.

This is an elderly female with chronic medical problems including hypertension, thyroid disease, and dementia, as well as decubitus ulcers. She lives with her son in a 4-bedroom house. The insurer approved personal care aide (PCA) Level 2: 24 hours per day - live in per diem - 7 days a week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is "severely impaired" and has declined since the prior assessment. She is dependent on activities of daily living including personal hygiene, dressing, bathing, and toilet transfer/use. She is incontinent of bowel and bladder. She is fed puree food due to the inability to chew/swallow food of regular consistency. The patient is bedbound and dependent on bed mobility. She remains at high risk for additional pressure ulcers. The patient has severe cognitive deficits with functional impairments that render her totally dependent and supports the medical necessity of PCA level 2: 12 hours/day - 7 days/week; 12 hours/day - 7 days/week (split shift) - a total of 168 hours/week. Her condition and functional needs are at a level and/or unpredictable as to require the requested continuous care split shift; 24 hours, 7 days/week; particularly as it relates to skin pressure relief, skin checks, and frequent turning. The patient's health and safety can be appropriately provided and maintained by increasing to PCA 12-hour split shift; 24 hours, 7 days/week.

The healthcare plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for personal care aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week is overturned. Medical necessity is substantiated.