Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease

Treatment personal care aide (PCA) services of 7 days per week, 2-12 hour split shift

The insurer denied coverage for personal care aide (PCA) services of 7 days per week, 2-12 hour split shift

The denial is overturned

This female has an extensive medical history associated with severe functional impairment. The patient is dependent on caregiver assistance for all activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient lives with her husband. He is identified as an informal caregiver in the UAS (uniform assessment system), but it is not clear whether he is able to provide care on a regular basis. The patient is receiving personal care aide (PCA) live-in services. Prior to live-in services, the daughter (does not live with patient) provided substantial amount of care each day. As noted in the Social Support section of the UAS, the daughter still provides care, but to a lesser extent with live-in services in place. A request was made to increase PCA services to 24 hours split shift (two 12 hour shifts per day); which was denied. An external appeal was requested. 

The UAS functional status indicates the patient is totally dependent for IADLs, except phone use (maximal assistance) and managing medications (extensive assistance). For ADLs, the patient no longer walks and is not transferred to toilet/commode (requires total care for incontinence). She is totally dependent for other ADLs; except bed mobility (maximal assistance), eating (extensive assistance).

The UAS indicates the patient has Parkinson's disease (PD). There are no details provided, but the UAS indicates patient has tremor, and nursing observation in the UAS noted stiffness in upper limb, which could be due to PD.  If the patient has had PD for a long time (advanced stage), this may at least partly account for the patient's impaired mobility. The UAS included carbidopa-levodopa in the medication list (primary treatment for PD). However, no medication for PD was in the UAS medication list. Parkinsonian symptoms can occur with certain medications (including some drugs that may be used to manage behavioral problems associated with dementia). Due to limited available information, the full effect of PD or parkinsonism on the patient's daily function is not known. 

Incontinence occurs at unplanned times of the day and night. The patient may remain clean and dry for a few hours, or she may urinate within an hour of the prior diaper change. There are complications of incontinence, especially for an elderly person dependent on caregiver assistance. Remaining in wet soiled diapers for several hours can result in incontinence associated skin damage (e.g., dermatitis, fungal infection) and is associated with increased risk of pressure ulcers.  

A possible complication of bowel incontinence is urinary tract infection. For a person with dementia, infection can increase risk of delirium, which is associated with further cognitive decline.

There is no information to suggest that the patient's husband or any other informal caregiver can provide assistance to the patient while a live-in aide is sleeping. Considering the request for increase of PCA services is for 24 hours split shift, it is reasonable to conclude that there are no informal caregivers who can provide ADL assistance to the patient for extended periods of time of the day or night on a regular basis. As per NYS (new York state) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance when needed for daily activities, including ADLs that occur at various unscheduled and recuring times throughout the day and night.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Services of 7 days per week, 2-12 hour split shift is overturned. Medical necessity is substantiated.