Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease with fall
Treatment: Increase in customer directed personal assistance service from 91 hours per week to 7 days per week, 2-12 hours split shift 
The insurer denied the increase in customer directed personal assistance service from 91 hours per week to 7 days per week, 2-12 hours split shift.
The health plan's determination is upheld.

The patient is female with past medical history of Parkinson's disease, dementia, depression, glaucoma, urinary incontinence, hypertension, cerebrovascular accident (CVA)/ transient ischemic attack (TIA), recurrent urinary tract infection (UTI) and lumbar disc disease who had personal care aide (PCA)/Consumer Directed Personal Assistance Program (CDPAP) services based on an assessment performed assessing the patient at total assistance with tasks of ordinary housework while requiring maximum assistance with tasks of meal preparation, shopping and transportation.

The patient lived on the first floor of a house with her daughter and son, had moderately impaired cognitive skills and due to her worsening Parkinson's symptoms had progressive dementia and memory loss. The patient was admitted to the hospital following a fall, urinary tract infection (UTI), moderate protein malnutrition and failure to thrive with subsequent transfer to rehabilitation. The patient's niece provided a letter outlining the timeline of the patient's stay at rehabilitation noting patient lost 10 pounds there, suffered 6 falls and had a decline in her physical and mental state. In planning for discharge to home the patient had another assessment performed assessing her at a total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, and equipment management while maximum assistance was needed for tasks of managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, toilet transfer and toilet use. Remaining tasks were at an extensive assistance level.

The insurer sent the initial adverse determination denial notice denying request to increase CDPAP services stating the service was not medically necessary, the patient had support from her family and lived with her daughter in a private house, the patient did not have a medical condition that would need for her to be turned and positioned every 2-3 hours, the patient did not have hands on continuous around-the-clock needs and the patient did not need someone to be awake for her all the time and safety monitoring was not a covered service. The patient's rehabilitation medical provider documented in a letter stating the patient's medical conditions and the patient should not be left alone and needs assistance with her daily living activities 24 hours a day, 7 days/week. On the same date, her primary care physician (or provider) (PCP) provided a letter stating the patient was in end-stage of life and required care 24/7 for her medical issues and the patient experienced hallucinations and insomnia which required her taking Seroquel.
The healthcare advocate provided another letter requesting an external appeal of the insurance denial decision noting the patient's medical conditions, including insomnia, which has not responded to medication. The advocate's letter noted the patient continuously tries to get up during the night and an aide must assist her in getting back to bed. The advocate's letter also stated the insurer incorrectly noted the patient did not have a decline in assistance needs with bathing and toileting. This was not true as the patient's condition had significantly declined. The advocate's letter also noted the patient's needs are frequent at night and are not predictable and live-in care is not an adequate plan of care and the patient does not have informal help as the insurer assumed. The patient's son and daughter both work full-time. 

At issue is the medical necessity of an increase in customer directed personal assistance service from 91 hours per week to 7 days per week, 2-12 hours split shift.

Although the patient has documentation of insomnia, there was no documentation of her care needs in the overnight hour with specific times and specific tasks in the form of a log indicating the patient's care needs overnight that would not allow a CDPAP aide to obtain at least 5 hours of uninterrupted sleep. There was no documentation from the patient's medical providers of the need to be turned and repositioned every 2 hours.  Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP 7 days per week, 2-12 hours split shift are not medically necessary for this patient.