Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, Glaucoma 
Treatment: Personal care Services, 24 hours a day, 7 days a week (split shift), for a total of 168 hours per week 

The insurer denied the Personal care Services, 24 hours a day, 7 days a week (split shift), for a total of 168 hours per week. The denial was overturned. 

This is a male patient with a medical history of coronary heart disease, hypertension, hypercholesterolemia, Parkinson's disease, tremor, dizziness, osteoarthritis, gait abnormality, benign prostate hypertrophy, functional urinary incontinence, glaucoma, dry eye syndrome, hearing loss, constipation, vitamin D deficiency. He reportedly lives alone and has had a significant recent decline in functional status. The patient had initially been approved for personal care services 56 hours per week. The family requested increase of services to 24 hours split shift which was denied; but approval was given to increase PCS to 84 hours per week. 

It is not clear whether the cause of the patient's recent decline is primarily due to PD/parkinsonism or other medical problems. The patient has a few diagnoses that can cause mobility impairment. He has osteoarthritis. Pain from arthritis can be debilitating. However, the UAS indicates the patient takes Tylenol and did not have pain in the previous few days; and so this is an unlikely cause of the patient's inability to walk. The patient has a diagnosis of dementia. The neurologist's notes indicate several signs of cognitive impairment (memory impairment, abnormal attention span, non-fluent speech). As dementia progresses to late stages, the affected person loses the ability to perform daily activities and mobility declines; but it does not appear from the available records that the patient is at such an advanced stage of dementia (neurology note indicated patient was oriented; understood commands well). The neurologist recommended neurology follow-up in the office; and follow-up with patient's PCP. 

Although the cause of the patient's loss of mobility is not clearly identified, the effect of the patient's functional impairment is more apparent. The patient's mobility has declined to a point where he no longer walks, and he needs maximal assistance for ADLs requiring lower extremity mobility (e.g. bathing, toileting, lower body dressing). He needs maximal assistance to transfer to a toilet or commode. He has difficulty or is unable to stand up without assistance. When the aide leaves each day, the patient is confined to bed. It was also noted that the patient's tremor is worse. The son-in-law reported the patient cannot activate his PERS due to tremor and decreased strength in his fingers; and this probably limits the patient's ability for most tasks that require hand dexterity. 

The patient's ability for self-care and mobility is severely impaired and it is medically necessary for the patient to have assistance for all daily activities, including ADLs that occur at various unscheduled times throughout the day at night (i.e. toileting/incontinence care; bed mobility/repositioning in bed; transfer out of bed if 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 Personal care Services, 24 hours a day, 7 days a week (split shift), for a total of 168 hours per week is substantiated. The insurer's denial is overturned.