Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Personal Care Aide (PCA) Level 2 Services: Live-in per diem, 24 hours per day - 7 days per week 
The insurer denied Personal Care Aide (PCA) Level 2 Services: Live-in per diem, 24 hours per day - 7 days per week 
The determination is overturned.


The patient with a past medical history of Parkinson's disease with dementia, benign positional vertigo, coronary artery disease (CAD), gastroesophageal reflux disease (GERD), benign prostatic hyperplasia (BPH), diabetes mellitus (DM) type 2, overactive bladder, lumbar radiculopathy and a history of cerebrovascular accident (CVA) who had been assigned personal care aide (PCA) services 7.5 hours/day, 7 days/week to total 52.5 hours/week based on an assessment tool performed. The patient had two falls. There was a request to increase PCA service hours. The patient had an assessment tool with assistance for tasks of meal preparation, ordinary housework, managing finances, shopping, walking and locomotion assessed at total assistance while tasks of managing medication, bathing, dressing lower body, transfer toilet and toilet use were assessed at maximum assistance. Tasks of transportation, personal hygiene, dressing upper body and bed mobility were assessed at extensive assistance while the tasks of phone use was assessed at limited assistance and he was independent with eating. This assessment was performed telephonically due to the Covid pandemic. There was an increased need for assistance with tasks of meal preparation, managing finances, stairs, bathing, personal hygiene, dressing upper and lower body, walking, locomotion, toilet transfer and toilet use.

The patient's neurologist wrote a letter on stating the patient had rapid progression of dementia with loss of ability to perform activities of daily living (ADLs). The insurer provided a final adverse determination denial notice stating PCA service hours would stay at 7.5 hours/day, 7 days/week to total 52.5 hours/week. The patient's neurologist provided a letter  stating that the patient was totally unable to walk and move lower extremities, had short-term memory loss, dizziness, ataxia, bradykinesia, cramping and numbness in the legs, back stiffness and muscle spasms. Another letter from patient's neurologist indicated that the patient needed 24 hour PCA services in split shifts due to the progressive condition of Parkinson's disease. The patient's primary care physician (or provider) (PCP) provided a letter stating the patient required maximum assistance with all ADLs and Instrumental activities of daily living (IADLs). The patient's wife wrote a letter stating that the patient cannot walk or hold his body weight and has had three recent falls at night requiring the ambulance to come to assist him up as the patient's wife is unable. The wife further responded to the insurer's denial letter stating she is supportive and involved in the patient's care but she is unable to meet all of his increased needs due to physical decline. She also noted that he often wakes up multiple times at night attempting to use the toilet and she is unable to help him out of the bed and/or transfer him to/from the wheelchair and toilet and position him in order to change him after toileting and/or change the bed sheets when he has a toileting accident. The letter noted the patient is not able to complete any part of the tasks of dressing his upper body, dressing lower body, personal hygiene, bathing, transfer toilet, medication management or bed mobility by himself and totally dependent on others to complete these tasks. He also needs help with eating although the assessment indicated he required set up only. The insurer provided another final adverse determination letter stating the decision to approve PCA service hours at 24 hours/day, 7 days/week was partially denied and was approved for PCA service hours at 9.5 hours/day, 7 days/week to total 66.5 hours/week. At issue is the medical necessity of Personal Care Aide (PCA) Level 2 Services: Live-in per diem, 24 hours per day - 7 days per week.

The patient has Parkinson's disease which is a progressive neurologic illness. There is documentation provided from the patient's neurologist citing the patient's clinical decline both physically and mentally. His providers note his inability to walk or move the lower extremity and his neurologist and PCP indicate that he needs 24 hour PCA services to help with ADLs. The patient had a telephonic assessment tool which underestimated his assistance needs for the tasks of bathing, personal hygiene, dressing upper/lower body, transfer toilet, toilet use, bed mobility and eating and since that assessment has had further progression of his parkinson's disease. The patient's wife is not able to provide needed assistance with ADLs and he has had 6 falls in the last 6 months. The patient's PCA hours are not soley for supervision and safety but to assist the patient with performance of ADL's and IADL's. 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 his own home.