Diagnosis: End stage renal disease.
Treatment: Personal Care Aide (PCA) Services 24 Hours (split shift) Per Day, 7 Days Per Week.

The insurer denied Personal Care Aide (PCA) Services 24 Hours (split shift) Per Day, 7 Days Per Week. The denial is overturned.

This elderly female has end stage renal disease, hypertension, hyperlipidemia, angina, neuropathy, and anemia. She is receiving hospice care. Denial of personal care aide (PCA) services 24 hours (split shift) per day, 7 days per week is being appealed. The plan approved personal care aide (PCA) live-in services, 7 days per week. A letter from visiting nurse service notes the member is unable to transfer alone, is incontinent of bowel and bladder and requires total care with all activities of daily living (ADLs). She requires turning every 2 hours and nighttime repositioning. Visit notes have been provided to support this information.

The proposed treatment is medically necessary.

Personal care services are necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. 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 aide 5 hours daily of uninterrupted sleep during the aide's shift. This member has multiple chronic conditions. She is in hospice care due to end stage renal disease. Denial of personal care aide (PCA) services 24 hours (split shift) per day, 7 days per week is being appealed. The plan approved personal care aide (PCA) live-in services, 7 days per week. The health plan denied the increase in hours because additional care is not indicated for supervision. The member has durable medical equipment (DME), include a rotating air mattress. A statement from her provider notes that the member requires total assistance with activities of daily living (ADLs), as well as turning and repositioning every 2 hours. She is incontinent of bowel and bladder. Office visits notes support this reported level of functioning. The appeal statements support that the member is dependent with all activities of daily living (ADLs) and requires frequent assistance with toileting, transfers, and turning/repositioning. This member has continuous needs that will not give the aide 5 hours daily of uninterrupted sleep during the aide's shift. The approved personal care aide (PCA) live-in services, 7 days per week are insufficient to meet this member's needs. The proposed personal care aide (PCA) services 24 hours (split shift) per day, 7 days per week are medically necessary.