Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split-shift) - a total of 168 hours per week
The insurer denied Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split-shift) - a total of 168 hours per week. 
The determination is overturned.

This is a male patient with a medical history notable for Parkinson's disease, dementia, and incontinence of bowel and bladder. The patient is approved for 7.5 hours per day, 7 days per week for a total of 52.5 hours per week of personal care assistance services. The patient and his care team requested an increase to 24-Hour per day (two 12-hour split shifts), 7 days per week for a total of 168 hours per week. 
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient has had multiple falls recently at home. These falls have been associated with injury. The patient is homebound and relies on others for activities of daily living. 
A Uniform Assessment System (UAS) was completed. The patient lives alone in an apartment. He was alert and oriented to person and place only. He is able to self-direct his care for basic needs but has difficulty with expressing himself. His short-term and procedural memory was not intact. For his instrumental activities of daily living, the patient requires maximal assistance or total dependence for all. For his activities of daily living, the patient requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, bed mobility, and eating. He requires total dependence for toilet use. He requires extensive assistance for hygiene and dressing upper body. The patient requires significant weight bearing assistance during walking and toilet transfers. He has a walker but is not able to use it due to severe tremors from Parkinson's disease. He is frequently incontinent of both urine and stool and uses Pull-Ups for incontinence care. He had one fall in the 30 days prior to the assessment. 
Nighttime care logs were provided for review. Throughout the night, the patient requires assistance every 2 to 3 hours with turning and repositioning as well as with toileting. Due to episodes of incontinence, he also requires assistance with changing diapers and changing soil sheets. At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split-shift) - a total of 168 hours per week. 

The requested health service of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split-shift)-a total of 168 hours per week is medically necessary for this patient.
The patient has pervasive care needs related to his activities of daily living. His mobility is severely limited secondary to his Parkinson's disease. He suffers from dementia and incontinence of urine in feces. His care needs are expected to be continuous and unscheduled throughout the day and night. The nighttime care logs demonstrate that the patient's care needs would not allow sufficient rest for a live-in personal care aide. He requires maximal assistance with turning and repositioning in bed, which is not unusual for a patient with advanced Parkinson's disease. Therefore, the request for an increase to 24-hour split shift care is medically necessary for the patient. Failure to provide for his personal care needs could result in skin breakdown, infection, or further morbidity.