Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, osteoarthritis, lumbar radiculopathy, lower back pain, age-related cognitive decline, diabetic neuropathy, diabetes mellitus
Treatment: Personal care services, 12 hours a day, 3 days a week
The insurer denied coverage for: Personal care services, 12 hours a day, 3 days a week.
The denial is: Overturned

The patient is an elderly adult who is functionally impaired due to various medical conditions and needs assistance with all activity of daily living (ADL's) and instrumental activities of daily living (IADL's). The patient lives alone. The patient has personal care services (PCS) 9 hours per day, 3 days per week; and Consumer Directed Personal Assistance Services (CDPAS) 48 hours per week. The patient (via designee) requested increase of PCS to 12 hours per day, 3 days per week, which was denied. 

The most recent Uniform Assessment System (UAS) provided for review was done. Functional status for IADL's indicates the patient needs maximal assistance for meal preparation, ordinary housework, shopping, transportation, stairs; extensive assistance for managing medications and finances, phone use. For ADL's, the patient needs maximal assistance for bathing, dressing lower body, toilet use; extensive assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet; limited assistance for bed mobility, eating. 

The letter of medical necessity from the nurse practitioner (NP) indicates the patient has Parkinson's disease (PD). Motor symptoms of PD include bradykinesia, rigidity, postural instability, unsteady gait, tremor; all of which can adversely affect ability to perform daily activities. 

The NP reported worsening of PD with increase in tremors, rigidity, loss of balance with falls. 

The UAS indicates the patient's gait is slow, unsteady with extensive assistance needed for walking/locomotion. The patient also has frequent dizziness.

The NP reports progression of memory loss and episodes of confusion. UAS medication list includes Namenda which is indicated for dementia/Alzheimer's disease.

The UAS includes diagnosis of chronic pain. UAS and NP indicate the patient has osteoarthritis. but pain, stiffness and decreased range of motion (ROM) are reported. The NP reported the patient has lumbar radiculopathy, lower back pain, and diabetic neuropathy. Tylenol is used to manage pain. 

The patient has history of falls, and the patient remains at high risk for falls. The patient risk factors include arthritis, PD, unsteady gait, dizziness, cognitive impairment, incontinence, use of medication associated with falls (e.g., Benzodiazepine/Temazepam). 

Managed long-term care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Additional PCS hours would not be for stand-alone safety supervision; assistance is needed for effective and safe completion of ADL's and IADL's. All the patient's care needs through the day must be considered in the determination of personal care service hours.  

Considering the information provided for review, personal care services (provided as PCS or CDPAS) are medically necessary for at least 12 hours per day to ensure all ADL's and IADL's are completed properly and safely; including meal preparation/service, housekeeping, routine ADL's and activities that occur at unscheduled and/or recurring times of the day. Assistance is necessary to help maintain skin integrity; prevent urinary tract infection (UTI); decrease occurrence of falls; facilitate safe, adequate food/fluid intake and help prevent hypoglycemia; ensure medication compliance; help with pain management. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care services, 12 hours a day, 3 days a week is substantiated.