Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Personal Care Aide (PCA) Level II: 56 Hours per Week (8 Hours per Day, 7 Days per Week)
The insurer denied Personal Care Aide (PCA) Level II: 56 Hours per Week (8 Hours per Day, 7 Days per Week)
The denial is overturned.

This is a patient with past a medical history of hypertension, hyperlipidemia, diabetes mellitus type 2, transient ischemic attack (TIA), ptosis of bilateral eyelids, spinal stenosis of the lumbar and cervical spine, osteoarthritis of the knees, urinary incontinence, recurrent urinary tract infection (UTI), chronic kidney disease, chronic anemia, history of pulmonary embolism, sacral pressure ulcer and recent diagnosis of Parkinson's disease who had previously been assigned 20 hours per week of personal care aide (PCA) services based on the assessment tool performed. The patient's assessment tool assessed her assistance for task of ordinary housework at maximum while tasks of meal preparation, managing medication, stairs, shopping, equipment management and bathing were assessed at extensive assistance. Tasks of managing finances, transportation, personal hygiene, dressing upper/lower body and toilet use were assessed at limited assistance while tasks of walking, locomotion and transfer toilet were assessed at supervision only. The patient was assessed as independent with the tasks of phone use, bed mobility and eating. The assessment notes state the patient used an assistive device of cane/crutch/rollator walker, was able to perform some light housekeeping, was able to prepare a sandwich, could transition from sit to stand and had daughter as informal helper. The patient was hospitalized with sepsis and had a subsequent transfer to Skilled Nursing Facility (SNF) with a return to home.
There was a request to increase PCA service hours and the patient had another assessment tool performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs and locomotion while tasks of shopping, transportation, bathing, dressing lower body and toilet use were assessed at maximal assistance. The tasks of managing finances, managing medication, equipment management, personal hygiene, transfer toilet and bed mobility were assessed at extensive assistance while task of eating assessed at limited assistance. The nurse's notes from this assessment state the patient lives with daughter, is wheelchair dependent, is a one person assist bed to chair, has no informal helper and has a sacral ulcer treated by the visiting nurse service (VNS) two times per week. There was a final adverse determination letter provided with partial approval to increase PCA hours to 30 hours/week and not to the requested 56 hours/week, stating the increase in hours was not medically necessary and additional hours would be for supervision and stand-alone. The patient's daughter provided a letter on stating the patient's daily care giving is extremely intensive and runs around the clock. Incontinence cares are prolonged due to the need to change, reposition and perform wound care with each bowel movement. Administering medication can take up to 20 minutes due to the patient's trouble swallowing. All meals are fed to the patient which can take up to 30 minutes. At least once or twice per week the patient is transferred to a wheelchair with the assist of two and a hoyer lift is used if the daughter is alone. The patient's health care advocate provided a letter noting the decline in patient's physical health and ability between the two assessment tools and that hospital records were not reviewed in the determination of PCA hours. At issue is the medical necessity of Personal Care Aide (PCA) Level II: 56 Hours per Week (8 Hours per Day, 7 Days per Week).
The requested personal care aide services are medically necessary. The patient has multiple medical problems including a recent diagnosis of Parkinson's disease with a significant change in her functional ability following a hospitalization. There is clear documentation of a significant decline in functional ability from the assessment tools . Specifically the patient was wheelchair dependent when she previously was able to ambulate with assistive device. The patient had a change in her assistance needs with all tasks except managing medications and equipment management. Furthermore the patient had a new decubitus ulcer that required frequent incontinence care, repositioning and turning. The patient's daughter provided a letter outlining the specific tasks and required time which is underestimated by the improved 30 hours per week of personal care services. PCA services in this patient are not solely for safety and supervision but for provision of assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The increase in PCA service hours is medically necessary as assistance with nutritional and environmental support and function is essential to the maintenance of the patient's health and safety in her own home.