Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: Personal Care Services: 23 Hours per Day, 7 Days per Week (Split-Shift).
The insurer denied Personal Care Services: 23 Hours per Day, 7 Days per Week (Split-Shift).
The determination is overturned. 

The patient is a female with a past medical history of dementia, hypertension, macular degeneration, Parkinson's disease, hyperparathyroidism, osteoporosis, basal cell cancer, moderate to severe dysphagia, and urinary incontinence who had Personal Care Aid (PCA) services 6 hours/day, 7 days/week to total 42 hours/week. There was a request to increase PCA services and the patient underwent a video assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing medication, phone use, stairs, transportation, and equipment management. With tasks of managing finances, bathing, dressing lower body, walking, locomotion, transfer to the toilet, and toilet use, the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene, dressing upper body, and bed mobility.

The patient was hospitalized with discharge summary noting the patient had poor oral intake and presented with hypernatremia, hypercalcemia, and acute kidney injury. The patient had a percutaneous endoscopic gastrostomy (PEG) tube placed with initiation of tube feeds due to moderate to severe oral dysphagia. The patient was treated for a urinary tract infection (UTI). The patient was seen by the wound care nurse noting pressure injury on the upper back and left hip with recommendation to turn and reposition every 2 hours and to apply medihoney.
At issue is the medical necessity of Personal Care Services: 23 Hours per Day, 7 Days per Week (Split-Shift).

The requested health service/treatment of Personal Care Services: 23 Hours per Day, 7 Days per Week (Split-Shift) is medically necessary for this patient.
The patient had a significant decline in functional status after the last video assessment. The patient was hospitalized with subsequent transfer to rehabilitation, and it was the patient/family's desire to discharge the patient to home. There were documented pressure injuries during her hospital stay with the wound care provider specifically noting two pressure ulcers and recommending turning and repositioning every 2 hours. The patient's care needs of turning and repositioning every 2 hours would not allow a PCA 5 hours of uninterrupted sleep. The patient requires assistance with walking, locomotion, transfer to the toilet, and toilet use and therefore has 24-hour care needs that are unpredictable and unscheduled. The insurer failed to document a plan to meet the patient's unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan indicated the patient had care needs that were out of the scope of a PCA but there is documentation that the daughter, who lives with the patient, could provide support for these care needs.
Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.