Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/ Neuromuscular Disorder - Parkinson's Disease
Treatment: Home Health Care - Personal Care Aide; 168 hours/week, 12 hours x 2 x 7 days-split shift; Consumer Direct, 1 client
The health plan denied the requested service as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a medical history notable for Parkinson's disease with gait disorder, Lewy body dementia, hypertension, and hypothyroidism. The patient was receiving 56 hours per week of consumer directed personal assistance services. Her care team requested an increase to 168 hours per week (24 hour per day split-shift) personal care services.
Support for this appeal was provided by the patient's neurologist, who has cared for the patient for 20 years. The specialist notes a rapid decline in physical and mental status in the patient, leading to trouble living independently. She has been having "more frequent vivid hallucinations" as well as worsening gait difficulty due to her Parkinson's. She has impaired speech with difficulty using the phone, which has led to multiple instances of the police being called. The specialist also expresses concern over an instance where the patient let a stranger into her house, and by the time someone else arrived the person was gone. The patient frequently misses medications and is at risk for choking while eating. In the reason for appeal request, the Power of Attorney (POA) states: "[Her] Parkinson's disease has progressed to the point that it is unsafe for her to be alone."
A Uniform Assessment System (UAS) was completed  and a prior assessment was available for comparison. The assessment found the patient to be alert and oriented but with episodes of forgetfulness. She is able to make her needs known. With regards to functional status, she requires total dependence for housework. She requires maximal assistance for meal preparation. She requires extensive assistance for managing medications, managing finances, and phone use. For her activities of daily living (ADL), she requires maximal assistance with locomotion. She requires extensive assistance for bathing, hygiene, dressing her upper/lower body, toilet transfer, and toilet use. She uses a wheelchair and can wheel herself a short distance. She is occasionally (less than daily) incontinent of urine and uses liners that she is able to change by herself. She is continent of stool. A Mini-Mental State Examination (MMSE) was performed with a result of 17/21, with points off for day, date, 5-minute recall (one out of three), and the last digit of serial sevens. An associated tasking tool recommended 31.2 hours of personal care assistance per week to address her needs. A functional assessment was similar to the prior examination, with only a slight decline.
At issue is the medical necessity of the requested health service/treatment of Personal Care Aide; 168 hours/week, 12 hours x 2 x 7 days-split shift.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment is not medically necessary.
This help is being requested primarily for safety and security monitoring purposes. These are not functions of level 2 personal care, and thus are not appropriate uses for full time split-shift personal care. The patient has functional needs as outlined on the UAS and associated tasking tool. The consumer directed aide should function to support these deficits as recommended by the neurologist, including supervision while eating and helping with ADL's and IADL's (independent activities of daily living). Additional time would be purely for the purposes of safety monitoring. Split shift services are reserved for patients with around-the-clock personal care needs such as sacral ulcerations in the setting of incontinence. There is no established medical necessity for split-shift services in this case.