Diagnosis: Cognitive Impairment
Treatment: Personal Care Services Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week
The insurer denied Personal Care Services Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week.
The health plan's determination is upheld.

The patient is a female with past medical history of dementia, coronary artery disease, constipation, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), hypothyroidism, chronic anticoagulation, permanent pacemaker, osteoarthritis, diabetes mellitus (DM) type 2, vitamin B12 deficiency, insomnia, hearing loss, urinary incontinence, and bowel incontinence who had been assigned PCA (personal care assistant) services.

Personal Care Services Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week are not medically necessary for this patient.
There is no documentation of overnight care needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. There is no documentation that the patient's residence does not have the appropriate space for a PCA to sleep. There is no documentation of the medical necessity of turning and repositioning every two hours. There are no specific overnight care logs documenting the activities of daily living (ADL) assistance needs in the overnight hours or the frequency of such need. 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, PCA services 24 hours/day, 7 days/week, split shift, to total 168 hours/week are not medically necessary for this patient.