Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease. 
Treatment: Personal Care Service (PCS) - 24 Hours a Day, 7 Days per Week (Split-Shift), for a Total of 168 Hours per Week.  

The insurer denied Personal Care Service (PCS) - 24 Hours a Day, 7 Days per Week (Split-Shift), for a Total of 168 Hours per Week.  The health plan's determination is overturned. 

The patient is a female with past medical history of Parkinson's disease, urinary incontinence, degenerative joint disease, irritable bowel syndrome, anxiety, osteopenia, constipation, allergic rhinitis, hiatal hernia with gastroesophageal reflux disease (GERD), coronary artery disease, chronic neck and low back pain, memory loss, diabetes mellitus type 2, anemia, and autonomic dysfunction who had been assigned PCA (personal care assistant) services. 

Personal Care Service (PCS) - 24 Hours a Day, 7 Days per Week (Split-Shift), for a Total of 168 Hours per Week medically are necessary for this patient. 

There is documentation of multiple falls secondary to the patient's progression of Parkinson's disease with an escalation of freezing episodes and on off periods, which are unpredictable, and the patient's Parkinson's medications cannot be increased further due to side effects. The assessment tool underestimates the patient's assistance needs during the day or night when she is having episodes of freezing secondary to her Parkinson's. The patient lives alone and has no informal help, requires assistance with all activities of daily living (ADL), and has unscheduled and unpredictable care needs that span a continuum of time, and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's medical provider did not recommend restriction of fluids, as this would adversely affect the patient's medical conditions. The patient has continuous care needs and a time-based assessment should not have been utilized by the plan to calculate PCA service hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). Given the unpredictable nature of the patient's freezing episodes and on off episodes related to her Parkinson's disease, it would be medically necessary for her to have an aide via split shifts to assist the patient with ADLs in the overnight hours at any time she requires it, as patient would be unable to activate a PERS (personal emergency response system)device in the event of a freezing episode or on and off episode. Because of treatment related to her Parkinson's disease, she does have visual hallucinations resulting in difficulty with sleep, and once awake the patient requires assistance with ADLs. Although the provider did not specifically document care needs at least every 2 hours, the patient's complex medical circumstance would necessitate an aide to be available for the patient's unpredictable care needs in the overnight hours, which would not allow an aide to obtain at least 5 hours of uninterrupted sleep. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, 7 days/week, split-shift, 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.