Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Personal care aide (PCA) level 2 services 24 hours continuous care 
The insurer denied personal care aide (PCA) level 2 services 24 hours continuous care. 
The determination is overturned.

This is a male patient with a medical history notable for Parkinson's disease, immobility, incontinence of bladder and bowel, active stage 2 sacral pressure ulcer, and weakness. The patient is approved for 7 hours per day, 7 days per week (49 hours per week) of level 2 personal care services. The patient and his care team requested an increase to 24 hour continuous care, and this request was denied by the health plan.

A physician's order for increased personal care hours was provided. The order states that the patient has limited mobility and requires turning and positioning to treat his pressure ulcer.
A recent office visit (telemedicine) note was provided for review. The patient was noted to require aides to lift him from the chair for transfers. He was using adult diapers for incontinence. The sacral wound is being seen by visiting nurses twice per week.
The patient requires assistance with all activities. She has taken off of work for the past 5 months to care for him, but she can no longer afford to do so and is returning to work. He will no longer have her for informal support.
A Uniform Assessment System (UAS) was completed on 10/26/22 and was available for review. The patient was alert and oriented to person and place only; he was confused and forgetful at times. From a functional standpoint, he requires total dependence for meal preparation and housework. He requires maximal assistance for managing medications, phone use, shopping, and transportation. For his ADLs, he requires maximal assistance for bathing, dressing lower body, walking, locomotion, and toilet use. He requires extensive assistance for hygiene, dressing upper body, toilet transfer, bed mobility, and eating. He is frequently incontinent of both urine and stool and requires a pull up change 4-6 times per day. A task tool associated with the assessment recommended 7 hours per day, 7 days per week to address his personal care needs. At issue is the medical necessity of personal care aide (PCA) level 2 services 24 hours continuous care

The requested health service/treatment of personal care aide (PCA) level 2 services 24 hours continuous care is medically necessary for this patient.
The patient has functional limitations which are pervasive and he requires human assistance for all ADL's and IADL's. In addition, he is dealing with a sacral pressure ulcer. He is frequently incontinent of stool and urine. The patient will require turning and repositioning every 2 hours to promote healing of his ulcer, and unscheduled toileting needs / pull up changes throughout the day and night. It is medically necessary for him to have 24 hour continuous care to meet these needs. These functional needs are well documented across multiple sources. The patient's daughter has been providing informal support but will no longer be able to continue to do so. The task tool cannot be relied on to accurately reflect his needs when he has frequent, continuous, and unscheduled personal care needs. If continuous care is not provided, the patient could suffer from worsening skin breakdown and/or infection.