Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: increase in 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 insurer denied increase in 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 determination is overturned.

The patient has a past medical history of Parkinson's disease, orthostatic hypotension, hyperlipidemia, urinary incontinence, osteoarthritis, gastroesophageal reflux disease (GERD), glaucoma with blindness in one eye, and human immunodeficiency virus (HIV) who had been assigned personal care assistant services (PCA) 8 hours/day, 5 days/week, and 7 hours/day, 2 days/week to total 54 hours/week based on assessment tool performed via telephone. At this assessment the patient was assessed at maximum assistance for all activities of daily living (ADL) /instrumental activities of daily living (IADL) tasks except for locomotion for which she was assessed at extensive assistance. Notes from this assessment stated the patient was self directing and alert and oriented. In addition, notes stated that the patient needed help with ADLs/IADLs as the patient stated she spent most of the day frozen and stiff and unable to move. The patient also reported that medications work for about 1 to 2 hours and it is unpredictable when the medication will start working. The universal assessment also stated the patient needed significant weightbearing support from the daughter to use a small stool in the tub, was unable to get into the tub daily and only showered 1-2 times per week when her daughter was able to assist, was able to complete personal hygiene and feed herself with significant weight bearing support due to dyskinesia, needed significant assistance with weightbearing for upper and lower body dressing due to stiffness and tremor, was able to ambulate with a slow onset gait with the use of a walker and weight bearing support with the use of a cane, was able to transfer from toilet with significant weightbearing support, needed assistant wiping herself properly and changing her pull-ups, was able to maneuver in bed with significant weightbearing support due to stiffness, had assistance from her family for cooking, cleaning, medication management, finances, and shopping.
The patient's neurologist provided Department of Health form stating the patient had severe immobility and severe dyskinesia with strong recommendation for deep brain stimulator surgery otherwise she had very poor prognosis. On the same date, the patient's neurologist completed "Medical Request For Home Care" form stating the patient had severe Parkinson's disease with severe dyskinesia, poor sleep, often up at night requiring split shift home health aide. In addition, the neurologist wrote a letter stating the patient had been experiencing an exacerbation of her symptoms which included severe gait and balance impairments, difficulties transferring, freezing episodes, rigidity, urinary incontinence, fatigue, hallucinations, insomnia, and heartburn. This letter also recommended that the patient's home care services be increased to two - twelve hour split shifts a day, seven days a week as she required total assistance with her ADLs such as toileting, dressing, bathing, and feeding throughout the course of the day and at night. Lastly, the neurologist's letter stated the patient requires medication reminders so that she can remain compliant with her medication regimen and her needs should be considered continuous due to current limitations as well as progressive nature of her disease.
The patient underwent another telephonic assessment tool assessing the patient at maximum assistance with all tasks except for managing finances, managing medication, and phone use for which she was assessed at extensive assistance. Notes from this assessment stated the patient was oriented and self directing. In addition, notes stated the patient's daughter reported the patient had a decline in functional status. The assessment notes stated the patient ambulated with a walker and maximum assistance x 2 people with weightbearing support, required assistance with getting in and out of the tub, bathing, transferring toilet, donning clothes, managing medication, transportation, house chores, laundry, shopping, and meal preparation. In addition, assessment notes stated the patient had fallen 3 times in the last 90 days.
The insurer sent initial adverse determination denial notice denying request to increase PCA services. The insurer sent a final adverse determination denial notice denying request to increase PCA services stating the patient did not meet criteria and the request was not medically necessary. The denial further stated a recommendation for physical therapy services, to continue to use the medical supplies provided, approved hours could be split into 2 shifts to better meet her morning and evening needs, aids do not manage medical conditions, and time was not provided for companionship, safety supervision, or when there was no task being done. The patient's neurologist requested an expedited appeal of the denial decision by the insurer.
The patient's healthcare advocate provided a letter requesting an external appeal on denial decision noting the patient had no family member who was able to assist her, the patient had a decline in her ability to perform ADLs/IADLs, had suffered several falls when the aide was not present, the amount of hours authorized by the plan was no longer enough to meet the members recurring and continuous needs, particularly in the evening and night, the members assistance needs were beyond safety supervision, she required prompting and cueing every 2 hours and 45 minutes so that she could remain compliant with her medication regimen, had overnight needs which could not be scheduled including toileting, transferring, and ambulation, the patient's daughter worked full-time and was unable to provide informal help, required hands-on assistance to sit up and turn in bed, was unable to use his adaptive equipment without assistance because of her medical conditions, and because of her Parkinson's disease might not be able to operate a personal emergency response system (PERS) adequately, due to her medications she has significant dry mouth and because of her limited mobility and motor functioning she was unable to get herself a glass of water when her aide was not present.
At issue is whether an increase in 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.

Yes, the services are medically necessary. There is documentation in the universal assessment tool and in the patient's neurologist's notes that the patient has had a decline in functional mobility due to her Parkinson's disease. There is documentation that the patient requires frequent dosing of medication at least every 2 hours and 45 minutes throughout the day and night. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not provide a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met with medical supplies and adaptive equipment alone. In the overnight hours, the patient requires assistance with medication management and administration, drinking, bed mobility, transferring to toilet, and toilet use in the overnight hours such that a personal care assistant would not be able to obtain at least 5 hours of uninterrupted sleep. The request for increased PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's medical provider has documented medical necessity for increase PCA services. The assessment tools that were performed indicate that the patient needs at least extensive assistance with all ADLs/IADLs and patient does not have informal help outside of the hours that the aide is present. 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, split-shift, 7 days/week, to total 168 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.