Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's disease, Cognitive impairment, left hand contracture, chronic pain, osteoarthritis, peripheral neuropathy, bladder and bowel incontinence, probable benign prostatic hyperplasia, impaired bowel motility, history of falls.
Treatment:  Personal care services (PCS) increase to 24 hours per day (split shift).

The insurer denied coverage for Personal care services (PCS) increase to 24 hours per day (split shift).  The denial is overturned.

Adult patient has extensive functional impairment associated with medical conditions and needs assistance with all daily activities. The patient lives with spouse. The patient has been receiving personal care services (PCS) 84 hours per week to assist with activities of daily living (ADL's) and instrumental activities of daily living (IADL's). The UAS identifies the spouse as the only informal helper. They explained that they are unable to continue providing informal care due to their own health issues. The patient (via designee) requested personal care services (PCS) increase to 24 hours per day split shift, which was denied; but the insurer increased PCS to 24 hours per day live-in. External appeal was requested. 

The insurer approved live-in services. The activity logs completed by the patient's spouse in indicate the aide was not present at night (departs at 8 or 9 pm) and nighttime care was provided by the spouse; so it appears the patient was still receiving PCS 84 hours per week.

The most recent Uniform Assessment System (UAS) provided includes functional status for IADL's as follows: Meal preparation, ordinary housework, shopping, stairs: total dependence; Transportation, managing finances, equipment management: maximal assistance; Managing medications: extensive assistance; Phone use: limited assistance. For ADL's: Dressing lower body, walking, locomotion, transfer toilet, toilet use: total dependence; Bathing: maximal assistance; Personal hygiene, dressing upper body, bed mobility: extensive assistance; Eating: setup help.

The records indicate the patient has Parkinson's disease (PD). As per UAS, the patient has had several falls. The patient's gait is unsteady. The patient has had several episodes of freezing of gait per activity logs. The spouse noted that the patient cannot transfer in and out of bed unassisted. 

The UAS indicates the patient has some degree of cognitive impairment. The spouses comments indicate the patient has decreased safety awareness. The activity logs indicate the patient has inconsistent sleep patterns and usually does not have more than 2-3 hours of uninterrupted sleep at night. 

As per UAS, the patient has left hand contracture and needs assistance with meals at times. 

The records indicate the patient has chronic pain. The patient has osteoarthritis. The physician reported patient has peripheral neuropathy. The patient has chronic swelling of lower legs (history of deep vein thrombosis (DVT); takes coumadin). 

The UAS reports the patient is totally dependent for toilet transfer and toilet use; and has frequent bladder and bowel incontinence. The records indicate the patient has impaired bowel motility. UAS reports 2-4 bowel movements and multiple diaper changes per day. Activity logs indicate patient uses suppositories to help stimulate bowel movement. The activity logs (5 days) indicate assistance was needed for toileting/incontinence care about 9-11 times per day (including 4-5 times between 10 p.m. - 7 a.m.). 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is substantiated.