Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's Disease.
Treatment: Live-In 24-Hour Personal Care Services.

The insurer denied the Live-In 24-Hour Personal Care Services.  The denial is upheld.

This patient is a female, who has conditions including Parkinson's disease and stroke.  She is appealing denial of live-in 24-hour personal care services (PCS). The plan is reducing services to personal care services (PCS) eight hours per day, seven days per week, total of 56 hours per week.  The patient was receiving dual care with her husband, who died.  The request was denied based on evaluation performed, which showed the patient needs assistance with meal preparation, housework, shopping, bathing, dressing, personal hygiene, and toileting,  She does not have incontinence.  

An appeal letter from the patient's child states her condition is progressing.  It notes the patient needs assistance with medications.  It notes she needs assistance with ambulation.  She has fallen multiple times between the commode and bed.  

An appeal letter from the provider notes the patient has Parkinson's disease, tremor, weakness, cognitive impairment, and gait difficulty.  She is at risk of falling.  She is unable to perform activities of daily living (ADLs).  

An appeal letter from another provider notes the patient needs continuous supervision as she has trouble ambulating on her own.  It notes the patient is dependent in assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADL).

No, the proposed treatment is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding.  

This patient has conditions including Parkinson's disease.  She is appealing denial of live-in 24-hour personal care services (PCS). The plan is reducing services to personal care services (PCS) eight hours per day, seven days per week, total of 56 hours per week.  The patient had been receiving dual services with her husband before his death.  The patient needs assistance with meal preparation, housework, shopping, bathing, dressing, personal hygiene, and toileting.  She does not have incontinence.  Appeal statements note the patient needs assistance with activities of daily living (ADLs) and is a fall risk due to gait instability.  Personal Care Services (PCS) are not indicated when no tasks are performed or for safety supervision.  The documents provided do not support the necessity for nighttime care.  The approved Personal Care Services (PCS) 56 hours per week is appropriate and medically indicated to meets the patient's needs for assistance with activities of daily living (ADLs) and personal care.  The proposed increase in to a live-in personal care service (PCS) is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.