Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Personal Care Services (PCS) 7 days 24 hours split shift
The health plan denied the PCS 7 days 24 hours split shift as not medically necessary.
The health plan's determination is overturned.

The patient is a male with a medical history of visual impairment secondary to macular degeneration, Diabetes, chronic obstructive pulmonary disease, osteoarthritis, Parkinson's disease, dementia, hypertension, and vertigo. The patient lives alone with no informal helpers. There has been a request for an increase of Personal Care Services (PCS) 7 days 24 hours split shift, for a total of 168 hours/week. Currently the health plan has approved PCS 8 hours, 7 days/week, total of 56 hours.

The patient was assigned services based on assessment, finding the patient with minimally impaired cognition. He was assessed to require total dependence with tasks of meal preparation and housework, and extensive assistance with medications. The patient was assessed at maximal assistance with task of bathing, extensive assistance with personal hygiene and dressing upper body, maximal assistance for dressing lower body and locomotion. He was assessed to need maximal assistance with toilet use and transfers, extensive assistance with bed mobility and limited assistance with eating. He is infrequently bladder incontinent and occasionally bowel incontinent.

The patient's primary care physician wrote a letter of medical necessity stating that patient's request for increased services to 24 hours is medically necessary. The physician noted that patient has multiple medical conditions including Diabetes, chronic obstructive pulmonary disease, osteoarthritis, Parkinson's disease, dementia, hypertension, and vertigo. It was noted that patient requires assistance with activities of daily living (ADLs) and due to memory loss; he requires prompting to perform tasks such as eating and taking medications. It was also noted that the patient needs assistance for his mobility and transfers and has urinary frequency due to diabetes with toileting both day and night.

At issue is the medical necessity of the requested increase of PCS 7 days 24 hours split shift, for a total of 168 hours.

The health plan's determination of medical necessity is overturned in whole.

The requested increase of PCS 7 days 24 hours split shift, for a total of 168 hours is medically necessary for this patient.

The patient requires assistance with many ADLs and instrumental activities of daily living (IADLs). The patient has dementia, visual impairment, as well as significant functional deficits. The patient requires hands on assistance for all mobility tasks and is unable to transfer independently, thus, he will need a care giver to be available during the day, as well as during nocturnal hours for assistance with toileting to decrease the risk of pressure ulcers. The requested increase in assistance is not solely for safety and supervision but to assist the patient with the safe completion of ADLs and IADLs. In addition, the patient has no informal helpers and lives alone. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCS 7 days 24 hours split shift, for a total of 168 hours are medically necessary for this patient.