Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease

Treatment: An increase in personal care aide hours to 7 days per week, 24 hours live-in

The insurer denied coverage for an increase in personal care aide hours to 7 days per week, 24 hours live-in.

The denial is overturned.

This is a male patient with multiple medical conditions and functional impairment who lives at home with his wife. His history includes: Parkinson's disease (PD), chronic pain, heart failure, lymphoma, anxiety, and depression. The patient has been experiencing acute flare-ups of his PD symptoms for the past few months and on those occasions he cannot talk or move to reach for the phone. Records indicate that the patient has had a significant decline in health and function, requiring increased assistance with daily activities. The patient was approved for personal care aide (PCA) 7 hours per day, 7 days per week. The patient requested increase of PCA services to 24 hours live-in, which was denied, but PCA services were increased to 56 hours per week.

According to the most recent Uniform Assessment System (UAS) documentation provided for review, the patient needed maximal assistance or total dependence for all instrumental activities of daily living (IADLs) except managing finances, medications and phone use (limited assistance). For activities of daily living (ADLs), the patient was totally dependent with walking, primarily using a wheelchair in the home. For the other ADLs the patient needed maximal or extensive assistance, except for eating (limited assistance). The UAS report of the patient's cognition noted modified independence for daily decision making, with no report of memory impairment. 

Considering the information provided for review (UAS reports, medical records), and the functional problems associated with PD, chronic pain, and heart failure, it is medically necessary for the patient to have caregiver assistance to properly and safely move around his home and complete daily activities throughout the day and night.  ADLs such as transfers, walking, toileting, incontinence care are not scheduled tasks and occur at various times throughout the day and night. The level of assistance needed may change during the day due to the variability of the patient's level of function throughout the day due to PD. 

The UAS indicates that the patient's wife is the primary informal caregiver. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. It is in the best interest of the patient and his wife to provide an alternate plan for the patient's care throughout the day and night.  Without informal caregivers who can provide care on a consistent basis when needed, personal care services are indicated to provide assistance with daily activities, including ADLs that occur throughout the day (i.e. transfer, walking, toileting, incontinence care). The frequency of nighttime ADL assistance for the patient is not known.  As per NYS regulations for live-in aide services, the assistance needed by the patient should be sufficiently infrequent so that the aide can obtain 5 uninterrupted hours of sleep within an 8 hour sleep period per day.  

PCA hours, 7 days per week, 24 hours live-in is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for an increase in PCA hours to 7 days 24 hours per week, live-in is overturned. The medical necessity is substantiated.