Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's disease, Lewy body dementia.
Treatment:  Personal care aide level 2: 8 hours per day - 7 days per week - a total of 56 hours.

The insurer denied personal care aide level 2: 8 hours per day -7 days per week - a total of 56 hours.  The determination is overturned.

The patient has a medical history notable for Parkinson's disease, Lewy body dementia, gait abnormalities, hypertension, and recent fall with a wrist fracture. The patient is approved for 4 hours per day, 7 days per week (28 hours per week) of personal care services. The patient and her care team requested an increase to 8 hours per day, 7 days per week (56 hours per week), which was denied by the insurance company. This denial is the subject under review.

A letter of medical necessity for this appeal was provided by the patient's primary care physician. The letter states that she lives alone and has no local family support. She has mobility limitations that affect her ability to perform activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). She has also had difficult to control blood pressure and frequent falls which have led to multiple emergency room visits. The physician attests that it is medically necessary for her to have an increase in personal care services.

A letter of medical necessity was provided by the patient's neurologist. The neurologist attests that the patient requires assistance with bathing, dressing, cooking, and toileting. She has had multiple falls due to not having adequate assistance with her functional needs.

A letter was also provided by the patient's physiatrist. The doctor states that she had a fracture in her right wrist and subsequently has had difficulty with doing her activities of daily living.

The patient's recent medical records were provided for review. The physician notes that the patient is demonstrating forgetfulness and psychomotor slowing. She lives alone and does not have nearby family support. She has pain and decreased range of motion in her right hand and wrist after her recent fall and fracture. She is alert but only oriented times two. Her gait is unsteady and she requires assistance. She demonstrated confusion about her medication regimen. She saw a neurologist after levodopa caused her to have visual hallucinations; the neurologist recommended an up-titration of galantamine over a 3 week period followed by reintroduction of levodopa.

A Uniform Assessment System (UAS) was completed and was available for review. She was noted to be disoriented to time with periods of forgetfulness and confusion. She had 3/3 five-minute recall. Cognition was noted to fluctuate at times. For her functional status, she requires total dependence for housework. She requires maximal assistance for meal preparation and shopping. She requires extensive assistance for managing medications. For her activities of daily living (ADLs), she requires extensive assistance for bathing, hygiene, dressing upper/lower body, and toilet use. She requires limited assistance for walking, locomotion, toilet transfer, bed mobility, and eating. She has daily episodes of urinary incontinence. She needs weight bearing assistance with toilet use and cleaning after toileting. She is continent of stool. She had recently sustained a wrist fracture while attempting to ambulate to the bathroom on her own and sustaining a fall. Compared with a prior Uniform Assessment System (UAS), the patient had a decline in function in the following domains: dressing upper body, hygiene, toilet use, toilet transfer, walking, locomotion, eating, and bed mobility. A task tool associated with the most recent UAS recommended 5 hours per day (35 hours per week) of personal care assistance to address her needs, an increase from the 4 hours per day recommended on the prior assessment.

At issue is the medical necessity of personal care aide level 2: 8 hours per day -7 days per week - a total of 56 hours.

The requested health service/treatment of personal care aide level 2: 8 hours per day - 7 days per week - a total of 56 hours per week is medically necessary for this patient.
The patient has had a functional decline along most domains since the prior assessment, and it is expected that she will need more personal care assistance to address these needs. Multiple physicians in her care team attested to her need for additional help with ADLs and IADLs. She can no longer perform any of these tasks independently. Due to her pain from arthritis and recent fracture, she is likely more slow to complete tasks even with assistance. She recently suffered a fall and fracture due to not having the assistance which she requires for toileting. This demonstrates the medical necessity for increased personal care hours. The hours are not meant for safety monitoring only, but to complete her personal care tasks which can no longer be done independently.