Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease, tremor, diabetes and
depression
Treatment: Increase Home Care/Personal Care HHC Level 2 Personal Care Services, Per 15  Minutes To 70 Hours Per Week
The insurer denied the Increase Home Care/Personal Care HHC Level 2 Personal Care Services, Per 15  Minutes To 70 Hours Per Week
The denial is upheld. 

The patient is a female with conditions including Parkinson's disease, tremor, diabetes and depression. The patient lives with her daughter's family in a house on the first floor. The patient is appealing the requested increase in Level 2 PCS (personal care services) from 49 to 70 hours per week.

Assessment performed shows modified independent cognitive skills and functional status; total dependence with housework; maximal assistance with meal preparation, managing medications, and shopping; extensive assistance with bathing; limited assistance with phone use, dressing, walking, locomotion, and toileting; and supervision with personal hygiene, bed mobility and eating. The patient is frequently incontinent of bladder. Assessment shows falls five times in the last three months. Compared to assessment performed earlier in the year, there is a decline in bed mobility, eating and managing medications. Her DME (durable medical equipment) includes cane and walker. Progress notes from office visits have been provided for review. The patient is involved in a DBS (deep brain stimulation) program. The provider notes that the patient is reported to have worsening gait, constipation and getting up frequently during night to urinate. The provider states the patient's condition is chronic and progressive. Despite family effort, the patient still has unobserved hours. Notes assistance is required for ADLs (activities of daily living) as already accounted for in the most recent assessment. Additional hours are requested to improve her observation and degree of assistance.

No, the Increase Home Care/Personal Care HHC Level 2 Personal Care Services, Per 15  Minutes To 70 Hours Per Week is not medically necessary.

Medically necessary services are those which are:
1) safe 
2) effective
3)  generally accepted national standard of medical practice 
4) not provided primarily for convenience of the patient or the practitioner 
5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is not medically necessary, because it is not consistent with generally accepted national standard of medical practice.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient was approved for 49 hours based on assessment performed most recently. This assessment shows the patient needs assistance with housework, meal preparation, managing medications, shopping, bathing, phone use, dressing, walking, locomotion, and toileting. There was minimal change compared to assessment performed earlier in the year: bed mobility and eating declined to require supervision and managing medications declined to requiring maximal assistance. The patient lives with her daughter's family who can provide informal support as well as share responsibility for some actives, such as housework and shopping. The provider is appealing the requested 70 hours per week to allow for observation due to family reporting unobserved hours. The approved 49 hours per week is sufficient to provide assistance with ADLs (activities of daily living) and personal care as noted above. PCS (personal care service) is not indicated for supervision or when there are no tasks being performed. The proposed increase in PCS (personal care service) to a total 70 per week is not medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.