Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease.
Treatment: Personal Care Assistance for 24 hours per day, 7 days per week, split shift.
The health plan denied Personal Care Assistance for 24 hours per day, 7 days per week, split shift.
The health plan's determination is overturned.

The patient is a male with a diagnosis of atypical parkinsonism, progressive supranuclear palsy and a history of prostate cancer status/post (s/p) transurethral resection of the prostate (TURP). He also has a history of dysphagia, bladder and bowel incontinence and a sacral decubitus ulcer. He has a recent history of an altered mental status secondary to toxic metabolic encephalopathy due to a recent Coronavirus (COVID-19) infection and a urinary tract infection (UTI). He was recently admitted to the hospital for failure to thrive and an altered mental status. He was subsequently transferred to a nursing and rehabilitation center following the hospital stay, where he currently resides. The patient continues to demonstrate hypoactive delirium. He suffered a traumatic fall due to his progressive decline in cognitive function along with his significant comorbidities and intermittent confusion. The nursing and rehabilitation center recommended increasing his personal care assistant (PCA) service after the initial nursing assessment indicated that the patient had the inability to complete his instrumental activities of daily living (IADL's) and activities of daily living (ADL's). Documentation by his neurologist recommended 24 hours per day of supervision for the patient due to his progressive supranuclear palsy.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient. The patient has the progressive neurodegenerative disease atypical Parkinson's and progressive supranuclear palsy. He has other comorbidities such as dysphagia, (he is on a dysphagia diet), bowel and bladder incontinence, and he had a recent hospitalization due to toxic metabolic encephalopathy. He also suffered physical and cognitive decline after a recent fall. Subsequent reevaluation determined an increase in PCA services to complete IADL's/ADL's such as preparing meals, housework, shopping, transportation, walking down the stairs and managing his medications. He is unable to perform the following ADL's such as bathing, personal hygiene, dressing upper body and lower body, toilet use and toilet transfers. Lastly, the neurologist documented that the patient has progressive supranuclear palsy and determined the patient is not safe to be home alone, that he has a high risk for falls and needs help with IADL' and ADL's. He also documented that the patient requires assistance 24 hours per day.

The requested health service and treatment of Personal Care Assistance for 24 hours per day, 7 days per week, split shift is medically necessary for the patient. This is based on the neurologist's recommendation and nursing assessment that indicated the patient's physical and cognitive decline and inability to complete his IADL's and ADL's.

The patient has progressive physical and cognitive declines. The patient had a recent hospitalization and traumatic falls. There is nursing assessment documentation of the patient's inability to complete IADL's/ADL's in the setting of his comorbidities which include, atypical parkinsonism, progressive supranuclear palsy, prostate cancer, osteoarthritis, dysphagia, an unsteady gait and bladder and bowel incontinence.