Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Parkinson's Disease
Treatment: Home Health Care
The health plan denied the requested increase in personal care assistance hours as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with a past medical history of Parkinson's disease, osteoarthritis, and urinary incontinence who had been assigned personal care assistance (PCA) service hours, 6 hours/day, 7 days/week, to total 42 hours/week based on an assessment tool provided, assessing the patient at total assistance with meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing finances, stairs, transportation, bathing, dressing lower body, and eating. The patient was assessed at extensive assistance with managing medication, phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility. Notes from the assessment stated the patient had upper and lower body tremors, unsteady gait, stiffness and limited range of motion. In addition, the note stated that the PCA fed the patient his meals, his spouse prepared his medication, he required significant weightbearing assistance with showering and dressing lower body, and used a rollator when walking both indoors and outdoors. The patient's wife was noted as his informal support. The patient's spouse moved to Puerto Rico due to her own medical conditions and there was a request to increase PCA services. The patient's neurologist provided a letter stating that the patient had severe basal ganglia disease which was getting worse and that he was not able to take care of himself. The provider noted that the patient needed at least 12 hours a day of aide services for safety and to help keep him clean and the patient has no family backup for assistance. At issue is the medical necessity of the requested increase in personal care assistance hours.

The health plan's determination of medical necessity is overturned, in whole.

The patient has a chronic, progressive, medical diagnosis of Parkinson's disease. The patient's neurologist has documented the patient's worsening symptoms. The patient no longer has informal support. The patient requires assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs). The telephonic assessment tool underestimated his assistance needs with walking, locomotion, transfer toilet, and toilet use. The patient 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. The patient's care needs cannot be met with current hours and/or adaptive equipment and/or medical supplies. The patient has episodes of unpredictable "freezing" for which he needs additional assistance. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. 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, to total 84 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.