Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, dysphagia 
Treatment: Personal Care Aide, level 2: 24 hours per day, Live-in per diem, 7 days per week 

The insurer denied coverage for Personal Care Aide, level 2: 24 hours per day, Live-in per diem, 7 days per week. The denial is reversed. 

This patient is a male who lives at home with wife. He has multiple medical conditions, several which have contributed to substantial functional decline. He had been receiving personal care aide (PCA) services 33 hours per week. Request was made for 24 hours live-in PCA services. This was denied by the insurer, but PCA hours were increased to 39 per week. The patient's wife provides some care, but she is unable to care for all his needs when the PCA is not present due to her own health problems. The patient has Parkinson's disease (PD), which is a progressive neurologic disorder that affects motor function, causing tremors, bradykinesia, rigidity, abnormal gait, postural instability, speech and swallowing problems. Non-motor effects of PD include cognitive impairment, hallucinations/delusions, mood disorders, sleep disorders, pain/cramps, constipation, blood pressure fluctuations (hyper and hypotension), fatigue. Based on description of the patient's problems as described in the available records, it appears that PD has had a substantial effect on the patient's functional decline. 

The UAS reported patient had one fall in previous 30 days. In the records from the physician and the night log, it is reported that the patient has had frequent falls. The fall noted in the UAS resulted in laceration to head. Head trauma and fractures can be potentially critical injuries. The patient has increased risk of falls due to PD, and also has other risk factors for falls including: arthritis, pain, BPH (increased urge to urinate/nocturia), incontinence, cardiovascular disease, cognitive impairment (physician noted patient is forgetful, confused). Fall prevention is a priority of the patient's care plan. Some interventions may help (e.g. physical therapy). However, the patient needs extensive assistance with transfers and ambulation; and so this needs to be a part of the care plan.

The patient is currently approved for PCA 39 hours per week. The patient needs assistance for ADLs beyond 6.5 hours per day/39 hours per week. The patient requires assistance with all daily activities, including those that occur at unscheduled and unpredictable times throughout the day and night (i.e. transfers, walking, toileting and incontinence care). The patient lives with his wife. In the care management notes, the wife reports that she is unable to provide all the care her husband needs due to her own health problems. In the night log it was noted that a neighbor was called to help the patient get up from the floor after a fall. The UAS identifies another informal helper who assists with ADLs and IADLs. However, in the care management notes, the wife reported that she is the only one who can assist her husband, so it appears the other helper cannot provide consistent and extended time for assistance to the bathroom but no help was available, which resulted in a fall. 

Personal Care Aide, level 2: 24 hours per day, Live-in per diem, 7 days per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the increase in personal care aide (PCA) level 2 services at 24 hours per day live in per diem for 7 days per week is substantiated. The insurer's denial is reversed.