Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's Disease, Dementia.
Treatment:  Personal care aide (PCA) Level 2: 12 hours per day-7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week. 

The insurer denied the personal care aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week.  
The denial was overturned.

This is a female patient with a medical history of dementia, Parkinson's disease, osteoarthritis, anemia, hypertension, osteoporosis, depression, dyslipidemia, overactive bladder, difficulty walking, unsteadiness on feet, muscle weakness, lower back pain, lumbar radiculopathy, urinary tract infection (UTI).  It was reported that the patient's functional abilities have worsened causing progressive decline in her ability to perform daily activities.  She lives alone, since her husband passed away within the past few months.  Her son lives in an upstairs apartment of a multifamily house.  She receives some assistance from a personal care aide (PCA) and family.  Patient (via designee) requested PCA 24 hours split shift, which was denied.  She was approved for PCA 35 hours per week (5 hours x 7 days). 

The patient has diagnosis of dementia and is taking donepezil.  UAS describes short term and procedural memory impairment, increased confusion and some impairment in decision making.  There are no available records of formal cognitive evaluation.  One possible indicator of her cognitive status is the high level of assistance she needs for IADLs.  For a person with dementia, functional decline with daily activities is an expected outcome of the disease as it progresses.  Decline of IADL skills usually occurs before loss of ADL ability; as IADLs generally require a higher level of cognitive function.  It is likely that the patient's dependence on caregivers for IADLs is a combination of physical and cognitive impairment.  It is not clear whether the patient's decline in several ADLs was partly due to cognitive impairment, but considering the increasing confusion, impaired memory, and impaired decision making, it is likely that she has decreased judgment and safety awareness, which may result in some unsafe choices when performing daily activities.

This patient has Parkinson's disease (not noted in the UAS).  Parkinson's disease (PD) can cause mild to severe functional impairment depending on stage of the disease and treatment efficacy.  The physician's office visit note did not include any physical findings on neuro exam that might be expected with PD; and the medication list did not include medication for PD.  Some of the patient's mobility problems identified in the UAS may be associated with PD (e.g. unsteady gait, stiffness, difficulty standing up from a seated position), but it cannot be determined from the available information whether Parkinson's disease has a significant impact on the patient's functional status at this time. 

Another concern is the patient's nutrition and hydration.  It was reported by the husband that the patient needs oversight and encouragement when eating, due to decreased appetite.  It is not unusual when frail, elderly people with cognitive impairment live alone that they experience nutritional decline.  With the current PCA schedule (5 hours per day), the patient probably has an aide present for breakfast and lunch.  For dinner, even with a pre-prepared meal, the patient may not remember or want to eat if she is alone. 

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

Based on the above, the medical necessity for Personal care aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week is substantiated.  The insurer's denial is overturned.