Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's Disease.
Treatment: Personal care assistance services, 24 hours per day, 7 days per week (split shifts) a total of 168 hours per week.
The insurer denied personal care assistance services, 24 hours per day, 7 days per week (split shifts) a total of 168 hours per week.
The determination is upheld.

This is a female patient with a past medical history of Parkinson's disease, dementia, neurogenic orthostatic hypotension, urinary incontinence, osteoporosis, and hyperlipidemia who had a fall with right hip fracture requiring surgical intervention. Prior to her injury, the patient had Consumer Directed Personal Care (CDPAP) services 40 hours/week. There was a request to increase services and the patient underwent an assessment via video assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, stairs, shopping, transportation, and dressing lower body. With the tasks of managing medication, phone use, equipment management, bathing, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. Tasking tool estimated 38.39 hours/week.
The insurer sent final adverse determination denial notice denying request for personal care assistant (PCA) services 24 hours/day, 7 days/week, split-shift, to total 168 hours/week. The denial stated the patient could not be left alone due to confusion and was unable to call 911 in an emergency. The denial also stated the assessment noted the patient lived with her daughter and son in law in a private two story home and they provided care outside of their work hours Monday through Friday from 7:30 am to 8:00 pm. In addition, the denial stated PCA hours for companion care or for safety supervision without the direct provision of activity of daily living tasks was not a covered service. Lastly, the denial stated there was no data showing the patient required someone to help turn and position the patient overnight and the patient used incontinence products such as diapers to manage urinary incontinence. The patient's neurologist provided a letter stating the patient's diagnoses of parkinsonism and dementia. The provider letter also stated the patient was dependent on assistance for all activities of daily living and required a minimum of 12 hours of home health aide assistant per day. The patient and her family appealed the denial decision with description of date and services stating a request for 12 hours a day, 7 days a week as her daughter was unable to care for her on the weekends. At issue is the medical necessity of personal care assistance services, 24 hours per day, 7 days per week (split shifts) a total of 168 hours per week.
The services are not medically necessary. There is no documentation of overnight care needs that would not allow a PCA 5 hours of uninterrupted sleep. Specific timed overnight logs were not provided for review. There is no documentation that the patient requires turning and repositioning every 2 hours. 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 24 hours/day, 7 days/week, to total 168 hours/week are not medically necessary for this patient.