Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: Personal care aide (PCA): 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week
The insurer denied PCA: 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week.
The determination is overturned.

The patient has a past medical history of progressive supranuclear palsy, dementia, Parkinson's disease, hypertension, osteoarthritis, osteoporosis, urinary incontinence, hypothyroidism, gastroesophageal reflux disease (GERD), constipation, and low back pain who had been assigned personal care assistant (PCA) services 6.5 hours/day, 7 days/week, to total 45.5 hours/week. The patient had a video teleconference assessment performed assessing the patient at total assistance with the task of ordinary housework and maximum assistance with the tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, and dressing lower body. With the tasks of managing finances, phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating the patient was assessed at extensive assistance.

The patient saw his neurologist, with the office note stating the patient had been stable, had 6.5 hours/day of a home health aide but needed assistance with activities of daily living (ADLs), got out of bed at night frequently, with more confusion during that time frame, climbed out of the bed rails, was occasionally aggressive and was confined to the wheelchair. The office note also stated the patient was having difficulty swallowing solids and had more impulsivity during the night. In addition, the office note stated the patient was having an increase in overnight hallucinations/agitation/confusion and needed assistance with ambulation and all ADLs at this time. The patient's medications were adjusted and patient was instructed to continue physical therapy (PT) and was referred for a swallowing evaluation.

There was a request to increase PCA services and the patient underwent an in-person assessment assessing the patient at total assistance with the tasks of ordinary housework, transportation, locomotion, and toilet use while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, shopping, bathing, personal hygiene, dressing upper/body, walking, and transfer toilet. Notes from the assessment stated the patient was moderately cognitively impaired, lived with his wife, ambulated with a walker at times but was mainly using a wheelchair. The tasking tool estimated 56 hours/week of assistance. The patient's neurologist provided a letter to document the medical necessity for 24-hour home care assistance as patient was unable to do ADLs, noting he had followed the patient in the office for the patient's long-term neurologic care with progressive supranuclear palsy. The provider noted the patient required assistance for functional needs including transferring, toileting, repositioning, and medication assistance and the patient experienced frequent dizziness on a daily basis, had chronic low back pain affecting his gait, and neurobehavioral problems including periods of confusion and hallucination.

The insurer sent an initial adverse determination denial notice partially denying the request to increase PCA services by approving 8.5 hours/day, 7 days/week, to total 59.5 hours/week. The denial recommended an evaluation for durable medical equipment (DME), continue follow-up with the primary care physician (or provider) (PCP) and neurologist, recommendation for door alarms and cameras to promote safety in the home, and a safety return bracelet. The insurer sent a final adverse determination denial notice continuing to approve 8.5 hours/day of PCA services, 7 days/week, to total 59.5 hours/week. The denial stated granting additional hours was not provided when tasks were not being performed and for safety monitoring and supervision and therefore increasing PCA services was not medically necessary. The patient's PCP provided a letter documenting the patient's diagnoses of chronic knee and back pain as well as osteopenia. The PCP provided another letter stating the patient required further assistance as he had Parkinson's disease, was bedbound, and was unable to ambulate without assistance. The family appealed denial decision. The patient's medical provider appealed the denial decision.

At issue is the medical necessity of PCA: 12 hours/day, 7 days/week (split shift), for a total of 168 hours/week.

The services are medically necessary.

There is documentation from the patient's PCP and neurologist of progression of his supranuclear palsy/Parkinson's disease resulting in overnight hallucinations, agitation, and confusion with the necessity to have assistance with eating, bed mobility, toileting, locomotion in the overnight hours. The patient's neurologist continues to see the patient on a regular basis with adjustment in medications to try to control the patient's overnight hallucinations, agitation, and confusion. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with the safe completion of ADLs and instrumental activities of daily living (IADLs), especially in the overnight hours. The patient is currently attending PT and being referred for a swallow evaluation. The family has installed safety measures to help to keep the patient safe but the progression of his illness causes him to be awake at night. While awake, he needs assistance with walking, locomotion, transfer toilet, and toilet use. He also needs help with bed mobility and eating. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer should not have used a task based tool to calculate the patient's hours. The patient's ADLs assistance in the overnight hours would be frequent enough that a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. 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/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.