Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease; dementia.

Treatment:  Increase Personal Care Aide (PCA) Services to 7 Days Per Week, 12 Hours Per Week x 2 (split shift), For a Total of 168 Hours Per Week.
The insurer denied the  Increase Personal Care Aide (PCA) Services to 7 Days Per Week, 12 Hours Per Week x 2 (split shift), For a Total of 168 Hours Per Week.

The denial overturned.

The patient is a female. Her medical conditions include Parkinson's disease and dementia. Denial of increase Personal Care Aide (PCA) Services, 7 days per week, 12 hours per day x 2, split shift, total of 168 hours per week is being appealed. She has been approved for 70 hours per week.

The daughter reports the patient has progressive dementia and Parkinson's disease and cannot be left alone.  She notes the patient has poor motor skills and increased confusion in the evening and nighttime.  The patient gets out of bed 3-4 times at night and becomes confused.  She notes the patient needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation.

The UAS (Uniform Assessment System) evaluation completed shows the patient is totally dependent with housework and requires extensive assistance with dressing, personal hygiene, bed mobility, walking, locomotion and toilet transfer; maximal assistance with bathing, toilet use, meal preparation, and medication management; and set up for eating.  She has DME (durable medical equipment) including PERS (personal emergency response system), shower chair, shower grab bar and incontinence supplies.  The patient lives alone.  Her children are supportive in her care.

An appeal statement notes the patient's Parkinson's disease and dementia have declined in the past 6 months.   The patient has chronic bowel incontinence since colectomy, which has progressed.  It notes the patient has unscheduled needs during night and early morning.  The patient's children provide informal support at night.  A letter reports that due to gait difficulties, toileting is challenging.  The patient needs helps getting out of bed several times per night to use the bathroom and then is unable to locate the bed.  The letter notes the patient is unsafe at night and requires 24/7 supervision for safety.  There is a night log provided that shows the patient gets up several times thru the night to go to the bathroom.  She gets up again about 4 hours later to go to the bathroom and/or wander.

Yes, the increase in Personal Care Aide services to 24 hours/day, 7 days/week, split shift, 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.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase Personal Care Aide (PCA) Services, 7 days per week, 12 hours per day x 2, split shift, total of 168 hours per week is being appealed. She has been approved for 70 hours per week.

This patient has chronic conditions including dementia and Parkinson's disease manifesting with poor gait and confusion.  UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living).  She has chronic bowel incontinence.  Appeal statements note the patient's cognitive and physical functioning have declined over the past 6 months, requiring increased PCA (personal care aide) hours.  Nighttime log shows the patient requires assistance with toileting approximately every four hours throughout the night.  This patient has continuous needs that cannot be met with the approved Personal Care Aide 70 hours per week.  The proposed increase in Personal Care Aide to 24 hours per day, split shift, is medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.