Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, dementia, hypothyroidism,
GERD, depression and anxiety
Treatment: Increase Personal Care Services (PCS) to 24 Hours Each Day 7 Days A Week (split shift)
The insurer denied the Increase Personal Care Services (PCS) to 24 Hours Each Day 7 Days A Week (split shift).
The denial is overturned. 

The patient is a female with diagnoses including Parkinson's disease, dementia, hypothyroidism, GERD (gastroesophageal reflux disease), depression and anxiety. The patient lives alone. She has two sons that are supportive. The patient is requesting an increase in PCS (personal care service) from 12 hours per day to 24 hours, split shift.

The patient's assessment performed shows minimally impaired cognition and functional status: Total dependence with housework and shopping; Max assistance with meal preparation, managing medications, transportation, bathing, and dressing; Extensive assistance with managing finances, phone use, personal hygiene, and toileting; Limited assistance with walking and locomotion; and Supervision with bed mobility and eating. The patient is frequently incontinent of bladder and wears a diaper.

An appeal statement from the patient's advocate notes the patient needs continuous PCS (personal care service) hours for unscheduled assistance with toileting and overnight ambulation associated with sundowning. It notes that the patient has had numerous falls after attempting to transfer from bed to walk to bathroom. Also, it notes the need for assistance with ADLs (activities of daily living) as already accounted for in the prior assessment. The provider NP (nurse practitioner) provided a statement to increase care to 24 hour split shift for this patient who is homebound and bedbound. The NP (nurse practitioner) provided a statement noting the patient has progressive dementia and recommending 24 hour, split shift, care to reduce the physical, mental or developmental effects of her current medical conditions. The patient's son provided a statement  that his mother's condition has declined over the past six months and she is no longer able to walk or use bathroom on her own. He notes that she has had several falls at night and is found on the floor by the day shift aide. She has been to the ER (emergency room) monthly after falling. She is more confused at night. She needs to go the bathroom at least twice at night, and she soils the bed one to two times per week overnight.

Yes, the Increase Personal Care Services (PCS) to 24 Hours Each Day 7 Days A Week (split shift) is medically necessary.

Medically necessary services are those which are safe effective generally accepted national standard of medical practice not provided primarily for convenience of the patient or the practitioner the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary, because it is consistent with generally accepted national standard of medical practice for this patient.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the provider five hours daily of uninterrupted sleep during the aide's eight-hour period of sleep.

This patient was approved for 84 PCS (personal care service) hours per week based on assessment performed. The patient lives alone. The assessment shows the patient needs assistance with housework, meal preparation, managing medications, transportation, bathing, dressing, managing finances, phone use, personal hygiene, toileting, walking and locomotion. After this assessment, the patient and her son were educated on safe transfer techniques and diaper changes. However, the patient's cognitive and functional status have declined since the assessment as documented in the appeal statement and letters from providers and the patient's son. The patient has fallen monthly from during nighttime when unassisted. She is now having more urinary incontinence occurring at nighttime and soiling the bed. Based on the progression of this patient's tremors due to Parkinson's disease and dementia, the currently approved 84 PCS (personal care service) hours per week are insufficient to meet this patient's nighttime needs for assistance with transferring, ambulation and toileting. The requested 24 hour, split shit, PCS (personal care service) services are appropriate for this patient.