Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's Disease.
Treatment:  Personal Care Assistance Services A Total of 2-12 Hours Per Day (split shift), 7 Days a Week.

The insurer denied Personal Care Assistance Services A Total of 2-12 Hours Per Day (split shift), 7 Days a Week.  The denial is overturned.

The patient is an adult female with a history of general debility due to Parkinson's disease. The request was for increase in Personal Care Assistance through Home Health care (Level 2) to 168 hours per week (24 hours per day/split shift of 12 hours x 2, 7 days per week), based on UAS (Uniform Assessment System) evaluation of 2 months ago against the previously approved 56 hours per week (8 hours per day, 7 days per week) of last year. She lives in an apartment alone with limited support from her son and daughter-in-law. The health plan denied coverage of the request, noting that the patient lives alone in a private home, has no medical needs for nighttime services, and her nighttime incontinence needs can be met by using nighttime devices and has no decubitus ulcers that may require her being turned in bed every 2 hours. The health plan further notes that the patient's needs can also be better followed through seeing her physicians, and someone to escort her for the physician's office visits can fit into the time already allotted. The additional hours requested are because of her chronic medical conditions, and to help with her Activities of Daily Living (ADLs) such as bathing, meal preparation, housekeeping, escorting to medical appointments, safety, supervision, etc. Her daughter-in-law and son direct her care. A review of the records showed that the patient has multiple chronic medical conditions, including cognitive decline, Parkinson's disease and its sequelae, recent CVA (cerebrovascular accident), need for PEG (percutaneous endoscopic gastrostomy)-tube feeding, recurrent UTIs (urinary tract infections), hypertension, GERD (gastroesophageal reflux disease), hyperlipidemia, depression, anxiety, breathing cancer, generalized osteoarthritis, aspiration pneumonia, etc. The patient's UAS (Uniform Assessment System) evaluation of 2 months ago showed that the patient is with history of prior nursing home placement, is severely cognitively impaired, totally dependent for most ADLs (activities of daily living), including meal preparation, housework, managing finances, managing medications, shopping, bathing, personal hygiene, upper/lower body dressing, toilet transfer, bed mobility, eating, and she is bed bound. These are worse than the patient's status noted in the UAS (Uniform Assessment System) from last year. The patient's family support is very limited, as she lives alone in an apartment, and she has support from her son and daughter-in-law.

The requested increase in Personal Care Assistance Services to 2-12 Hours Per Day (split shift), 7 Days a Week, is medically necessary.

Based on the patient's UAS (Uniform Assessment System) evaluation of 2 months ago, she is totally dependent for all ADLs (activities of daily living) etc. Her family support is very limited, as she lives alone in an apartment, and her son and daughter-in-law provide some support. The reasons cited by the health plan in their denial of coverage, as noted in the clinical summary above, do not align with her disability features as noted in the UAS (Uniform Assessment System) evaluation of 2 months ago.

Therefore, based on the UAS (Uniform Assessment System) evaluation of 2 months ago, the increase in service hours to 168 hours per week (24 hours per day/split shift of 12 hours x 2, 7 days per week) is medically necessary, because the patient is totally dependent for all of her ADLs (activities of daily living).