Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Parkinson's Disease
Treatment: Home Health Care- PCA Personal Care Aide
The health plan denied Personal Care Services; 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week as not medically necessary.
The health plan's determination is overturned.

This is a male patient with an extensive medical history, including poor functional status, reduced mobility, urine and fecal incontinence, cognitive impairment due to dementia, Parkinson's disease, coronary heart disease with pacemaker in place, peripheral vascular disease, gout, osteoporosis, and post-traumatic stress disorder (PTSD). His treatment team requested 24 hours per day, 7 days per week (split-shift) in-home personal care services (total of 168 hours per week). The plan partially denied this request, but did approve personal care services 24 hours per day, 7 days per week (live-in) for a total of 91 hours per week (allowing a minimum of 5 hours of continuous rest period for the live-in aide). The patient and his treatment team are appealing this decision which is the subject of the review.
The patient's primary care physician wrote a letter of appeal concerning this request. The physician states that the increase in hours is medically necessary and outlines the extensive list of medical needs for which the patient requires assistance. The letter notes that the patient is of reduced mobility and has incontinence of feces and urine requiring unpredictable changes of soiled diapers to prevent skin breakdown. The physician notes rapid cognitive, physical, and functional decline which has resulted in the need for human assistance in nearly all activities of daily living.
A Uniform Assessment System (UAS) community health assessment was completed. At that time, the patient was alert and oriented (A&O) times (x) 2-3 with "periods of forgetfulness and confused at times." The patient was noted to have declined cognitively from the previous assessment. From a functional standpoint, the patient is unable to get up without help, needs assistance getting in and out of bed, and needs maximum assistance for toileting, bathing, dressing, transferring, and walking. He was noted to have bladder incontinence daily and bowel incontinence semi-daily.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Personal Care Services; 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week is medically necessary for this patient. The hours provided by the live-in aide would normally allow for an acceptable amount of coverage, and it is not the responsibility of the personal care assistant to ensure safety and security as this is not a covered service under the plan. However, the patient's most recent UAS (which is already nearly 6 months old) demonstrates ongoing incontinence issues. The patient's primary care physician notes explicitly that split-shift assistance is required to change soiled diapers to preserve skin integrity. This is not a task that can be scheduled, and it is not reasonable to assume that a live-in aide would always get 5 hours of uninterrupted sleep at night. The health plan's recommendation to use condom catheters to control continence issues overnight does not address the problem of fecal incontinence. Without prompt attention to continence care, skin breakdown and further complications are likely to ensue as indicated by the treating physician. Given the progressive and rapid decline in all areas of functioning, this patient's long-term prognosis is for continued decline and increasing levels of need over time.
Therefore, the requested health service/treatment of Personal Care Services; 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week is medically necessary.