Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease and hypertension
Treatment: Increase Consumer Directed Personal Care Services to Live-in 7 Days/Week
The insurer denied: Increase Consumer Directed Personal Care Services to Live-in 7 Days/Week
The denial is overturned.

The patient is an elderly male. His conditions include Parkinson's disease and hypertension. Denial of increase consumer directed personal care services to live-in 7 days per week is being appealed. The health plan approved increase from 28 hours per week to 42 hours per week. The Uniform Assessment System (UAS) evaluation completed last month shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with managing finances and shopping; extensive assistance with meal preparation, managing medications, bathing, and lower body dressing; limited assistance with upper body dressing, walking, locomotion, toilet use; supervision with personal hygiene; and independent with bed mobility and eating. The patient has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed six months ago, there has been a decline with housework, lower body dressing, personal hygiene, walking, locomotion, and toilet use. A letter from the patient's provider notes the patient has been experiencing more psychological and physical concerns, including hallucinations and delusion. The patient is at increased risk for falls due to coordination and balance. The provider recommends 10 hours of service daily. Additional records are provided showing the patient's falls and incontinence.

The requested increase in Consumer Directed Personal Care Services to Live-in 7 Days/Week is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase consumer directed personal care services to live-in 7 days per week is being appealed. The health plan approved increase from 28 hours per week to 42 hours per week.
This patient has conditions including Parkinson's disease. Uniform Assessment System (UAS) evaluation completed last month shows the patient requires assistance with all ADLs (activities of daily living), except bed mobility and eating. Compared to UAS (Uniform Assessment System) evaluation completed six months ago, there has been a decline with housework, lower body dressing, personal hygiene, walking, locomotion, and toilet use. He has bowel and bladder incontinence. There is an appeal statement noting decline in psychological and physical functioning. The patient is at an increased risk for falls due to poor coordination and balance. The information provided shows that this patient has significant limitations in functioning and requires significant assistance with ADLs (activities of daily living). The approved personal care services of 42 hours per week are insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase in personal care services to live-in 7 days per week is medically necessary.