Diagnosis: Gait Dysfunction.
Treatment: Personal care aide (PCA) level 2: 12 hours per day-7 days per week; 12 hours per day- 7 days 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 days per week; 12 hours per day- 7 days per week (split shift) - for a total of 168 hours per week. The determination is overturned.

This is a female patient with a medical history notable for end stage renal disease on dialysis and gait dysfunction. The patient is approved for 5.5 hours per day, 7 days per week (38.5 hours per week) of level 2 personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week) and this request was denied by the health plan.

The patient is currently residing in a skilled nursing facility after recovering from a hospitalization. Progress notes from this facility were provided and reviewed in detail.
A social worker from the nursing facility provided a letter of support for this appeal. The letter states that she was intended to stay there only for short-term rehabilitation. The letter states that her current allotment of 38.5 hours is insufficient to meet her needs if she is discharged.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was completed in the skilled nursing facility. The patient was alert and oriented to person and place. Her recall was 1/3 at five minutes. She is self-directing but forgetful. For her instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, finances, medications, stairs, and transportation. For her activities of daily living (ADLs), she requires total dependence for locomotion. She requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She is frequently incontinent of urine and continent of stool. She uses pullups for incontinence care. Compared with a prior UAS, she showed a decline across several functional domains. At issue is the medical necessity of personal care aide (PCA) level 2: 12 hours per day-7 days per week; 12 hours per day- 7 days per week (split shift) - for a total of 168 hours per week.

The requested health service of personal care aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) - for a total of 168 hours per week is medically necessary for this patient.

The patient requires hands on assistance for all ADLs and IADLs. She is dependent on others for functional needs, including assistance for toileting and incontinence care. These are, by definition, unscheduled and continuous personal care needs. She lives by herself and requires this assistance to be safely discharged home. If she does not receive this care, she will be required to spend 18 plus (+) hours per day in the same soiled diaper, which could result in skin breakdown and/or infection.