Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: Personal care service 10 hours a day, 7 days a week, totaling 70 hours.
The insurer denied Personal care service 10 hours a day, 7 days a week, totaling 70 hours.
The determination is overturned.

The patient has a past medical history of Parkinson's disease with a history of a deep brain stimulator, dementia, osteoarthritis, anxiety, depression, hypertension, diabetes mellitus type 2, and hypothyroidism who had been assigned personal care assistant (PCA) services 5 hours/day, 7 days/week to total 35 hours/week. The patient saw her neurologist with an office note stating the patient had tried donepezil but was worse, a prescription for the physical therapy was provided, a prescription for wheelchair was provided, and the patient's Sinemet dose was increased. The patient's neurologist provided a letter stating the patient's diagnoses of Parkinson's disease and dementia associated with Parkinson's disease and that both were progressive diseases with progression of disease noted since the patient's last visit to the provider. The provider noted the patient required assistance with all activities of daily living (ADLs), supervision, and prompting.
In addition, the provider noted it was in the patient's best interest to be approved for no less than 10 hours/day, 7 days/week to maintain the patient's quality of life and safety which was her ultimate goal. The patient underwent an assessment assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, stairs, transportation, bathing, transfer toilet, and toilet use. With the tasks of personal hygiene, dressing upper body, walking, locomotion, bed mobility, and eating the patient was assessed at limited assistance while set up only for task of phone use. Notes from the  assessment noted the patient had increased weakness and an increased Nursing Facility Level of Care (NFLOC) score. The assessment also stated the patient had several falls.
The family provided an appeal request form documenting the patient's condition and that it fluctuates and can be worse at time, the patient needs assistance with toileting, adjusting clothes, meal preparation, help with transfer from stairs, transfer from toilet/commode, and noted informal support was not present 1 PM to 8 PM daily. The insurer sent an initial adverse determination denial notice denying the request to increase personal care assistant (PCA) services stating the request was not medically necessary, the patient could split her current hours to meet her morning and evening needs, the patient could obtain a lock box to hold the key for her door, the patient could get safety knobs on her stove, the plan provided incontinence supplies to help manage the patient's toileting needs, physical therapy was recommended, and the plan did not provide safety monitoring when no other personal care tasks were being performed.
The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating some of the handwritten information provided on appeal statement was illegible, it was not in the scope of practice of the aide to manage medical conditions, recommended the patient always use mobility device for safety as an aide cannot always be with the patient while present in the patient's home to prevent falls, recommended a referral to occupational therapy (OT)/physical therapy (PT), PCA services for companionship or safety was not a covered service, and the patient should speak to a care coordinator to recommend a more suitable and safe setting for the patient.
The patient's neurologist provided a letter stating the patient was being treated for Parkinson's disease and dementia associated with Parkinson's disease which were both incurable and progressive conditions that require assistance with all ADLs. In addition, the letter from the neurologist stated the patient's condition had recently worsened resulting in multiple falls and the need to transition to a wheelchair for transferring safely and the patient required full assistance with ADLs. The provider recommended 7 hours of Home Health Aid (HHA) services, 5 days/week, and 5 hours a day on weekends. The patient's primary care physician (or provider) (PCP) provided a letter noting the patient's medical conditions had made it difficult for the patient to perform activities of daily living and if she did not receive the additional hours/services there is potential for future falling and deterioration in physical condition and function. The patient's provider appealed the denial decision. Care logs from document assistance needs on an hourly basis 7 AM to 7 PM daily. The patient's daughter provided a letter stating the patient is left alone from 1 PM to 8 PM most days as the daughter and her husband work, the patient had demonstrated functional decline as well as cognitive decline resulting in an increased need for assistance with ADLs and Instrumental activities of daily living (IADLs).
At issue is the medical necessity of personal care service 10 hours a day, 7 days a week, totaling 70 hours.
The requested services are medically necessary.
There is documentation from the patient's neurologist and primary care physician, and the patient's daughter of functional and cognitive decline. There is documentation of multiple falls in the months prior to her last assessment. The patient's daughter and son-in-law are unable to provide informal care outside of all of the currently assigned PCA hours. The patient requires at least extensive assistance with transfer toilet and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The plan recommended physical therapy in which the patient had already participated. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. There is documentations from the patient's neurologist and PCP of medical necessity of increased PCA services. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 10 hours/day, 7 days/week, to total 70 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.