Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease 
 
Treatment: Personal Care Aide 7 days x (2) 12 hours split shift  

The insurer denied the Personal Care Aide 7 days x (2) 12 hours split shift. The denial was reversed. 

This is a male patient with a history of Parkinson's disease (PD), dementia, depression, hallucinations, hyperlipidemia, hypertension, atherosclerotic heart disease, gastroesophageal reflux disease (GERD), urinary incontinence, B12 deficiency. The patient currently has a personal care aid 7 days a week for 12 hours per day; 9am -9pm. The patient's spouse is requesting an increase of coverage hours due to the deterioration in his medical condition. It was reported that during the overnight hours the patient is semi awake and hallucinates and has periods of incontinence. Due to the patient's symptoms and inability to sleep throughout the night, the patient's spouse is required to attend to his needs; essentially leaving her without sleep. She has expressed deep concern for her own health as she is the primary caregiver to the patient. If she becomes ill and is unable to care for the patient, she fears his health will further decline.    

At this advanced stage of PD, the patient requires care with all ADLs. Even if the patient slept through the night, he would require incontinence care and repositioning through the night to prevent incontinence associated skin injury and pressure ulcers. The behavior and motor problems that occur during the night are more difficult to manage. A caregiver is needed to monitor for potential injury from involuntary movements and to provide some type of behavioral intervention if the patient is anxious and attempts unsafe movements to get up from bed. 

It is not unusual that informal caregivers can become overwhelmed with the mental and physical stress of care-giving, especially when the caregiver is not able to obtain adequate sleep. Caregiver stress is a serious and potentially dangerous consequence of providing care for a chronically ill person. The caregiver's health is often compromised either by lack of adequate attention to the caregiver's own health maintenance or from acute problems such as injury from heavy lifting or inadequate sleep. Physical symptoms as well as fatigue or anxiety can result in inadequate care provided by the caregiver resulting in possible harm to the care recipient.

Based on the information in the UAS, the physician's records, case management notes, sleep study, and the patient's wife, it is evident that the patient needs a caregiver present throughout the day and night to provide ADL care and to address symptoms that are associated with PD (e.g. leg cramps, behavioral symptoms).  The patient's wife is an elderly woman who is at significant risk when providing physically stressful tasks in order to care for her husband. As per NYS regulations for personal care services, assistance provided by informal caregivers is voluntary. The wife is asking for help because she no longer can provide the care her husband needs without risking her own health. In order to provide proper and timely care to the patient throughout the day and night, including toileting/incontinence care and turning/repositioning it is medically necessary for a caregiver to be present and able to provide care throughout the day and night.

Based on the above, the medical necessity for Personal Care Aide 7 days x (2) 12 hours split shift is substantiated.  The insurer's denial is reversed.