Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease.
Treatment: Personal care services live-in 24 hours.
The insurer denied personal care services live-in 24 hours.
The determination is overturned.


The patient has Parkinson's disease, diabetes, coronary artery disease (CAD) and a history of a cerebrovascular disease. She had a recent hospitalization for a stroke with increased needs following this. She required assistance with ambulation and a change to a pureed diet.
Documents report that the patient's Parkinson's disease is worsening. She has difficulty ambulating and is unable to walk by herself. She has had multiple falls even trying to get from her bed to a bedside commode. These falls were remedied when prior 24-hour services were available. According to the documentation provided needs 24-hour services were provided for in the setting of a "dual case". Services were made available for the patient as well as her spouse. Upon the passing of her spouse, services were reduced to 8 hours a day.
The patient is on multiple medications and takes these multiple times a day. Because of her medical conditions, she needs assistance with medication administration.
Documentation also reports that the patient has a tremor. This is associated with her Parkinson's disease. Because of this tremor, she not only has impacts on her ambulation, but other fine motor tasks associated with activities of daily living.
According to the documentation, both the patient's neurologist and primary care physician (PCP) recommended 24-hour care. Further review shows that her tremor also impacts her ability to check and monitor her own blood sugars. The patient needs assistance with preparing meals, housekeeping, laundry, shopping, bathing, dressing, personal hygiene and toileting. Documentation states that the patient may need to use the toilet a couple times overnight. She has had times where she has had incontinence and needed assistance with changing her clothes and bed linens. The patient, family and her physicians are requesting 24 hours of in-home care.
The patient's health plan is recommending 8 hours of in-home care on a daily basis. They recommended splitting this in 2 to 4-hour shifts to try to meet her care needs.
At issue is the medical necessity of personal care services live-in 24 hours.
The requested services are medically necessary. The care plan approved by the plan, 8 hours a day, 7 days a week is insufficient to meet her care needs and increases her risk for medical complications, hospitalization, morbidity and mortality.
Her needs were apparent prior to her more recent hospitalization for a stroke with her underlying Parkinson's disease and corresponding ambulatory dysfunction being limiting enough to warrant 24 hour care. Her subsequent stroke has  further set her back in her gait and ambulation as well as eating and drinking needs and additional activities of daily living (ADLs).
The denial letter states that giving more hours does not prevent falls or injuries. It states that an aide cannot always watch the patient. However, in this case, the patient is able to be self-directed and request assistance when needed. In the case of her gait, ambulation and fall risk, she does need assistance with transfers, walking and getting to and from the commode, even the bedside commode. Therefore, although an aide may not be able to specifically watch her at all times, in this instance since the patient is self directing she can call for assistance when this is needed. The presence of an aide, in this context, does prevent the patient from falling (as evidenced on the letter provided by the son explaining change in frequency of falls before and after prior 24 hour services). Review of the information provided demonstrates that the patient has needs with ambulation, transfers and toileting throughout the day as well as overnight, and would be insufficiently assisted with services provided only for 8 hours a day, even if they were divided into 2 separate shifts.

The health plan's determination is overturned in whole.