Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease/Falls. 
Treatment: Personal care aide (PCA) level 2: 12 hours per day- 7 days a week; 12 hours per day- 7 days a week (split shift) total of 168 hours per week. 

The insurer denied Personal care aide (PCA) level 2: 12 hours per day- 7 days a week; 12 hours per day- 7 days a week (split shift) total of 168 hours per week. 

The determination is overturned. 

The patient has multiple medical problems including dementia, Parkinson's disease, atrial fibrillation, hypertension, obstructive sleep apnea, diabetes mellitus type 2, anemia, urine incontinence, and bowel incontinence who had personal care assistant (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week. The patient had a fall and a coronovirus infection. The patient was in rehabilitation with discharge planning to include an increase in PCA services. Physical therapy notes from rehabilitation indicated that the patient required moderate assistance with wheelchair management. Occupational therapy reports noted the patient required moderate assistance with upper body dressing, transfers, and bed mobility. 
The patient underwent a universal assessment via telephone while at the Skilled Nursing Facility (SNF) assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, and locomotion while maximum assistance with tasks of phone use, bathing, dressing lower body, walking, and toilet use. The patient was assessed at extensive assistance with tasks of personal hygiene, dressing upper body, and transfer toilet while assessed as independent with bed mobility and eating. Notes from this assessment stated the patient was unable to express care goals due to cognitive changes and also noted the patient's wife was elderly and had her own health issues and had been having difficulty providing the patient the physical care he needed.
The patient's wife's neurologist provided notes stating that the wife had her own cognitive limitations and was having difficulty maintaining a safe home and managing the patient's medical needs. The patient underwent another telephonic assessment once he was home assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, and toilet use while maximum assistance with tasks of bathing, personal hygiene, dressing upper body/lower body, walking, locomotion, transfer toilet, and bed mobility. The patient was assessed at limited assistance with task of eating. Notes from this assessment stated that the wife was unable to provide care and the daughter was unable to stay overnight. 

The patient had a telemedicine visit with his neurologist noting the patient had progressive Parkinson's disease and was virtually non-ambulatory. This office note also stated the patient was not able to use the bedside commode as he was unable to get out of the commode once completed. Lastly, the note stated the elderly wife could not manage the patient on her own and the recommendation was for a home health aide 24 hours/day. The insurer sent an initial adverse determination denial notice denying request to increase PCA services to 24 hours/day, split shift, 7 days/week, to total 168 hours/week stating the patient's current PCA hours were appropriately and safely meeting the patient's personal care needs. The patient's primary care physician (PCP) provided a letter stating the patient's wife could not manage him alone with his gait and cognitive deficits and he would benefit from more hours of care. 
The patient's daughter provided a letter stating the patient's care needs have increased since last year, specifically requiring overnight care 2-3 times per night and the patient's wife was unable to provide that care. The insurer sent a final adverse determination denial notice denying request to increase PCA services, specifically stating many of the patient's abilities to perform physical functioning stayed the same since the prior assessment performed. The denial also stated the assessment did not support the need for nighttime hours from the aide and that additional hours are not provided for stand-alone safety supervision, companionship, or when the aide is not performing tasks. Lastly, the denial stated that notes from rehabilitation, the patient's PCP, and a letter from the daughter were reviewed in making this decision. 
Overnight care logs noted the patient required assistance with full toileting from 12 AM to 9:30 AM 2-3 times per night. The patient also required a full change of clothing overnight on at least 2 occasions. The patient saw his PCP with the office note stating the patient had bilateral leg swelling and was not ambulating/wheelchair-bound and the patient's wife had recently had a heart procedure and the daughter was trying to get more help at home. The patient's PCP provided a letter stating the patient would greatly benefit from 24-hour care to assist with all daily living such as toileting, transferring, walking, dressing, bathing, eating, and bed mobility. The letter also stated 12 hours a day was inadequate for the care of the patient with a progressive disease and he has no one to care for him at his home after the 12 hours of care ends. Lastly, the letter stated the provider feared that the patient's health would aggressively decrease without 24-hour care. The patient's neurologist provided a letter stating it was imperative for the patient to receive 24-hour care per day noting the patient's Parkinson disease had severely impacted his balance, gait, and mobility. 
At issue is the medical necessity of personal care aide (PCA) level 2: 12 hours per day-7 days a week; 12 hours per day- 7 days a week (split shift) total of 168 hours per week medically necessary for this patient. 

The requested services are medically necessary. There is documentation from the rehabilitation staff, the patient's neurologist, and the patient's PCP that due to worsening cognitive and functional status the patient requires an increased amount of PCA services. There is also documentation that the patient's wife is not able to provide that care due to her own medical conditions. The patient has no other informal help. The insurer did not provide a plan to meet the patient's additional care needs. The initial universal assessment underestimated his care needs when comparing recommendations from occupational therapy (OT) and physical therapy (PT) at the rehabilitation facility. The patient requires assistance with all activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) and 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 in the overnight hours. Overnight logs indicate that the patient requires assistance with ADLs in the overnight hours such that a live-in PCA would not be able to obtain 5 hours of uninterrupted sleep. Increased PCA services/hours are not solely for safety and supervision but to assist the patient with safe completion of ADLs. 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 12 hours/day - 7 days a week, 12 hours/day - 7 days a week, split shift to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.