Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Home Care / Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift) 
The insurer denied: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift) 
The denial is: Overturned

The patient is a male with medical history notable for Parkinson's disease, incontinence, and dementia. The patient was approved for 28 hours per week of level 2 personal care services. The patient and his care team requested an increase to 24 hours per day (2-12 hour split-shift), and this request was partially denied by the health plan; they did approve an increase to 70 hours per week.

The patient's physician provided a letter of medical necessity for this appeal. The letter states that a recent therapy evaluation showed that the patient requires at least contact guard or minimal assistance for all transfers and ambulation. He has had five falls in the past year due to lack of supervision. The patient's daughter works full time and cannot provide complete support during her work hours.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented to person and place only with periods of forgetfulness and confusion. He is not able to make his needs known or direct his own care. From a functional standpoint, he requires total dependence for meal preparation, housework, finances, and shopping. He requires maximal assistance for medications and transportation. For his activities of daily living (ADLs), he requires maximal assistance for bathing, hygiene, dressing, and toilet use. He requires extensive assistance for walking, locomotion, toilet transfer, and eating. He requires limited assistance for bed mobility. He is frequently incontinent of urine and stool and wears pull-ups for incontinence care. Compared with a prior UAS, he showed a decline in both cognition and functional status.
Nighttime logs were provided for review. The patient would have 1-10 nighttime instances of personal care needs each night. These were typically centered around toileting. He needed assistance with getting to the commode, changing of a soiled diaper, and/or changing of bedding after incontinence instances.

The requested health service of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift) is medically necessary for this patient.
The patient requires hands-on assistance for all personal care needs. He is unable to direct his own care. He has incontinence of stool and urine and requires assistance with diaper changes. His recent falls due to lack of adequate assistance with ambulation are evidence of unmet personal care needs. Nighttime logs demonstrate that 24-hour live-in care would not be sufficient to meet his personal care needs (as a live-in aide would not be able to get the required amount of rest overnight due to the patient's frequent needs). Therefore, it is medically necessary for the patient to receive split-shift 24 hour care. Failure to support his functional needs could result in falls, skin breakdown, and/or infection.