Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease.
Treatment: Personal Care Aide (PCA) Level 2: 10 hours per day - 7 days per week - for a total of 70 hours per week.

The insurer denied Personal Care Aide (PCA) Level 2: 10 hours per day - 7 day(s) per week - for a total of 70 hours per week.  The determination is overturned.

The patient is a male with a past medical history of legal blindness secondary to glaucoma, anxiety, depression, insomnia, ischemic cardiomyopathy, coronary artery disease (CAD), gout, dementia, Parkinson's disease, osteoarthritis, degenerative disc disease of the lumbar spine, and urinary incontinence who had been assigned personal care assistant (PCA) services 6 hours/day, 7 days/week, to total 42 hours/week. A tasking tool is estimated to be 31.5 hours/week.

There was a request to increase PCA services, and the patient underwent a video assessment assessing the patient at the same level of assistance as the previous assessment. The tasking tool estimated 31-point hours per week. Physical therapy discharge notes from home care stated the primary care physician (PCP) had referred the patient for physical therapy due to functional decline in activities of daily living (ADLs), noting the patient was contact guard for transfers, ambulation, and ADLs.

The patient's PCP provided a letter requesting an urgent increase in hours of home care for the patient due to his rapidly deteriorating mental and physical health and functional status. The letter stated the provider believed it was very important and medically necessary for the patient to have 12 hours of home care, 7 days/week to maintain his current health and functional capacities and to prevent illness progression.

The insurer sent a final adverse determination denial notice continuing to deny a request to increase PCA services, stating they had reviewed the letter of medical necessity from the patient's medical provider and visit notes from home health care, and a new assessment was not done, and the patient's status had declined since his previous assessment. At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 10 hours per day - 7 day(s) per week - for a total of 70 hours per week. 

The services are medically necessary. There is documentation of the medical necessity of increased PCA services. There is documentation of worsening functional status from previous video assessments and physical therapy assessments. The patient's last informal caregiver, his daughter, passed away earlier in the year, and the patient has no informal support. The patient requires at least limited assistance with tasks of walking, locomotion, transfer toilet, and toilet use and, therefore, has unpredictable and unscheduled care needs that span a continuum of time, and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 10 hours/day, 7 days/week, to a total of 70 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to maintaining the patient's health and safety in his home.