Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease 
Treatment: Personal Care Assistance: 7 Days x 24 Live-In Hours per Week (Monday through Sunday)
The insurer denied Personal Care Assistance: 7 Days x 24 Live-In Hours per Week (Monday through Sunday)
The health plan's determination is Overturned

The patient is a male with medical history notable for Parkinson's disease, dementia, and mobility issues. The patient is approved for 8 hours per day, 5 days per week for a total of 40 hours per week of personal care assistance. The patient and his care team requested an increase to 24-hour live-in care, 7 days per week. This request was denied by the health plan, and this denial is the subject under review.
The patient's caseworker provided a letter of support for this appeal. The letter states that the patient has an aggressive form of Parkinson's disease, and he is not able to do any of his activities of daily living (ADLs) without assistance. This includes toileting, hygiene, walking, and dressing. Because some of these needs will occur on an as needed and unscheduled basis, the caseworker states that his current hours are inadequate to meet his needs.
A Uniform Assessment System (UAS) was completed in person. The patient was alert and oriented with periods of forgetfulness. He is able to direct his own care and make his needs known. For his instrumental activities of daily living, the patient requires maximal assistance for meal preparation, housework, and shopping. He requires extensive assistance for transportation. He requires limited assistance for finances and medications. For his activities of daily living, he requires extensive assistance for bathing, dressing his lower body, and toilet use. He requires limited assistance for dressing his upper body, walking, locomotion, and toilet transfer. He is frequently incontinent of urine and continent of stool. He wears pull-ups to manage incontinence care and requires personal care assistance to change incontinence supplies and clean up after toilet use. There was one fall in the previous 30 days. There was no pressure ulcer present. A task tool associated with the assessment recommended 23.31 hours per week to address the patient's personal care needs.
At issue is the medical necessity of Personal Care Assistance: 7 Days x 24 Live-In Hours per Week (Monday through Sunday).
The health plan's determination of medical necessity is overturned in whole.
The requested health service of Personal Care Assistance: 7 Days x 24 Live-In Hours per Week (Monday through Sunday) is medically necessary for this patient.
The patient has functional limitations secondary to his Parkinson's disease and other age-related debility. As outlined in the assessment, he requires assistance with toileting, incontinence care, and dressing. Because needs for toileting and incontinence care can be continuous and unscheduled throughout any 24-hour period, his care needs cannot be compressed into the current 8-hour period that he has a home health aide. Furthermore, his fall within the past month is evidence of unmet personal care needs as he experienced a fall while attempting to perform personal care tasks without the appropriate assistance. Therefore, the requested increase to a 24-hour live-in personal care is medically necessary for the patient. Failure to provide for his personal care needs could result in additional falls, infection, and/or skin breakdown.