Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease. 
Treatment: Personal Care Aide (PCA) Level 2: 19 hours per day 4 day(s) per week; 20 hours per day - 2 day(s) per week; 12 hours per day - 1 day(s) per week - for a total of 128 hours per week. 
The insurer denied coverage for Personal Care Aide (PCA) Level 2: 19 hours per day 4 day(s) per week; 20 hours per day - 2 day(s) per week; 12 hours per day - 1 day(s) per week - for a total of 128 hours per week. 
The denial is upheld. 
 
This is an elderly female with Parkinson's disease. She lives alone in a private residence. The patient is approved by the insurer for PCA Level 2: 7 hours per day - 4 days per week; 8 hours per day - 2 days per week; consumer directed personal assistance program (CDPAP): 12 hours per day - 1 day per week - 5 hours per day - 4 days per week - 4 hours per day - 2 days per week - for a total of 84 hours per week. Her request for an increase in Personal Care Aide (PCA) services for 19 hours per day 4 days per week; 20 hours per day - 2 days per week; 12 hours per day - 1 day per week - for a total of 128 hours per week is currently under review. 

According to the more recent Uniform Assessment System (UAS) report, the patient's cognition is described as minimally impaired. She is able to dial 911 if needed and has a Personal Emergency Response System (PERS). She is reportedly maximal assistance to total dependent for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, personal hygiene, dressing, locomotion, toilet transfer/use and ambulation. Extensive and limited assistance are reportedly needed for bed mobility and eating, respectively. She reports being frequently incontinent of bladder and bowel. 

The patient's functional ability has not significantly declined when compared to the prior UAS report. Her cognitive status and ability to perform activities of daily living are much the same. The letters from the patient's treating physicians describing her clinical condition and functional impairments were reviewed. However, the associated treatment notes are inconsistent with her reported functional incapacity. The patient was seen by one of the two treating physicians less than a year prior to presentation. At that time, the patient had "minimal cogwheeling. Power 5/5, able to stand without assist, good stride, but shuffling with turns." The physician does not indicate there were any specific abnormal movements, coordination was intact and she was using a rollator for ambulation. Unfortunately, the office visit notes from the other of the two treating physicians are hand-written and illegible. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in Personal Care Aide (PCA) services for 19 hours per day 4 days per week; 20 hours per day - 2 days per week; 12 hours per day - 1 day per week - for a total of 128 hours per week services is not substantiated.