Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease with dementia

Treatment: Personal Care Aide (PCA) Services Level 2 of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The insurer denied coverage for Personal Care Aide (PCA) Services Level 2 of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The denial is overturned

The patient has a history of Parkinson's disease (PD) with dementia, schizophrenia, depression, gastritis, urinary incontinence, leg swelling, migraines, orthostasis, vitamin deficiency and ventral hernia repair.  The patient has physical and cognitive impairment which limits his ability to perform routine daily activities. He receives personal care aide (PCA) services 8 hours per day, 5 days per week, total of 40 hours per week. It appears the family is not able to continue providing the level of care the patient needs during non-PCA hours. An increase of services to PCA 24 hours split shift, 168 hours per week is requested.

Based on the available records, the patient has multiple motor and non-motor problems associated with Parkinson's Disease (PD) and dyskinesia. The neurologist's office reported patient was worse since last visit. The patient had mild tremor, mild to moderate slowness, stooped posture, gait instability and needed a caregiver for support with walking. He had difficulty moving to a standing position. The patient had cogwheel rigidity with contracture of upper extremities. He had episodes of dizziness, which may be at least partly due orthostatic hypotension (OH). Additionally, the patient has significant cognitive impairment, attributed to dementia. His ability to make decisions for daily tasks is consistently poor/unsafe; he has substantial memory impairment; his communication skills have declined. The patient has frequent delusions and hallucinations. The records indicate the patient also has diagnosis of schizophrenia, which may be another cause of delusions and hallucinations. The patient exhibited behavioral problems including agitation and resisting care. 

The patient is at risk for pressure ulcers. He needs extensive assistance with bed mobility, and so it is unlikely the patient can effectively reposition himself on a regular basis when he is in bed. The patient's risk for pressure ulcer is also increased due to incontinence. The patient has been losing weight, and so his nutritional status may be declining, which is another risk factor for pressure ulcers. A pressure relief mattress on the bed could be helpful but does not replace the need for turning and repositioning on a regular basis to fully relieve pressure on areas of the body (e.g., sacrum, hips), especially in a high-risk patient. Pressure ulcers are a source of pain and can result in complications such as infection/sepsis and possible surgical intervention. Pressure ulcer prevention is a necessary aspect of the patient's care plan. 

MLTC (Manage Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. All the patient's care needs that occur throughout the day and night must be considered in the determination of the patient's personal care service hours. The patient needs assistance for (activities of daily living) ADLs that occur throughout the day and night; and so additional PCA service hours in the evening/night are not for stand-alone safety supervision.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Personal Care Aide (PCA) Services Level 2 of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is overturned. Medical necessity is substantiated.