Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Parkinson's Disease. 
Treatment: Personal Care Aide 7 days x 12 hours. 

The health plan denied the requested Personal Care Aide 7 days x 12 hours as not medically necessary. 
The health plan's determination is overturned. 

This is a case review for a female with a medical history notable for Parkinson's disease, unsteady gait, osteoporosis, and incontinence. The patient is approved for a personal care aide 8 hours per day, 6 days per week and 3 hours per day, 1 day per week (51 hours per week). The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan. This denial is the subject under review. 

The patient's daughter provided a letter of support for this appeal. The letter states that the patient has a great deal of difficulty with ambulation secondary to her medical conditions. She had three falls in a month. All falls occurred when no aide coverage was present. The falls resulted in various injuries and associated pain. Photo evidence of the falls (and injuries) was provided for review. The patient's decreased hours on Sundays "poses a special threat" due to the amount of time she spends alone. The daughter feels that the additional hours that were requested are necessary to keep her mother out of a nursing home. The letter also expresses concern that the Uniform Assessment System (UAS) does not accurately reflect her mother's current functional status. The daughter is no longer able to provide informal support to her mother due to her own age and medical problems. 

Case management notes for the past year were provided for review. They corroborate the dates of the falls as outlined in the letter from the patient's daughter. A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented but forgetful at times. For her instrumental activities of daily living (IADL), she required total dependence for housework. She required maximal assistance for meals, shopping, and transportation. She required extensive assistance with finances and medications. For her activities of daily living (ADL), she required extensive assistance for bathing, dressing lower body, toilet transfer, and toilet use. She required limited assistance for hygiene, dressing upper body, walking, locomotion, and eating. She ambulates with a 1 person assist for contact guard and uses a wheelchair outside. She is frequently incontinent of urine and infrequently incontinent of stool and uses pullups for incontinence care. 

At issue is the medical necessity for the requested health service/treatment of Personal Care Aide 7 days x 12 hours. The health plan's determination of medical necessity is overturned, in whole. The requested health service of Personal Care Aide 7 days x 12 hours is medically necessary for this patient. 

The patient is of advanced age and has severe functional limitations secondary to Parkinson's disease and chronic pain. She had three falls in the month prior to the request for additional aide hours, and all of the falls occurred when she did not have a personal care aide available. She requires assistance with ambulation and toileting, including managing incontinence care. Her personal care needs can be expected to be unscheduled in nature throughout the day. Therefore, it is medically necessary for her to have a personal care aide available during the majority of the daytime hours as requested to address her personal care needs.