Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, dementia, muscle weakness, unsteady gait, and incontinence.
Treatment: Increase Home Care/Personal Care Level 2 Per 15 Minutes To 24 Hours Per Day (live in).
The insurer denied the Increase Home Care/Personal Care Level 2 Per 15 Minutes To 24 Hours Per Day (live in).
The denial is overturned.

The patient is a male. His medical conditions including Parkinson's disease, dementia, muscle weakness, unsteady gait, and incontinence. Denial of increase home care/personal care level to 24 hours per day, live in, is being appealed. The health plan approved increase from 42 to 49 hours per week, based on decline in some areas of physical functioning.

UAS (Uniform Assessment System) evaluation completed shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, bathing, lower body dressing, and toileting; extensive assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, and bed mobility; and limited assistance with eating. The patient sleeps on the sofa due to inability to get out of the bed. He is frequently incontinent of bladder. He urinates in diaper due to poor coordination with urinal. The PCA (personal care assistant) notes urine overflows onto sofa. The patient's DME (durable medical equipment) includes rollator, urinal, commode, pull-ups and Chux.

An appeal statement from the patient's social worker notes that the patient's needs for assistance with ADLs (activities of daily living) are live-in services. The appeal notes the patient's level of functioning has declined over the last several months. He has had three falls in last three months.

A letter from the patient's physician notes the patient's Parkinson's is progressing and his level of functioning has declined since last letter. The letter notes the patient requires assistance with all ADLs (activities of daily living) and has more frequent incontinence with unscheduled overnight needs.

Yes, the requested increase in personal care services to 24 hours/day, live-in, is medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. The patient is appealing denial of increase home care/personal care level 2 to 24 hours per day, live in. The health plan approved increase from 42 to 49 hours per week.

This patient has progressive Parkinson's disease and dementia. UAS (Uniform Assessment System) evaluation completed shows he needs assistance with all ADLs (activities of daily living). He is incontinent of bladder. This evaluation shows decline compared to the prior UAS (Uniform Assessment System) evaluation. Appeal statements note that the patient's Parkinson's is progressing, and his level of functioning has declined over the last several months. His urinary incontinence has increased. He has been observed to have incontinence overnight. This patient has a progressive condition resulting in declining physical functioning. He requires significant assistance with all ADLs (activities of daily living). The patient's needs for frequent assistance with incontinence and transfers cannot be met with the approved PCS (personal care services) 49 hours per week. The proposed increase in PCS (personal care services) to total to 24 hours per day, live in, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.