Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease. 
Treatment: Personal Care Services (PCS) 24 hours a day, 7 days a week (live-in) for a total of 91 hours. 

The insurer denied: Personal Care Services (PCS) 24 hours a day, 7 days a week (live-in) for a total of 91 hours. 
The denial is overturned. 

The patient is a female with a medical history notable for Parkinson's disease, incontinence, and arthritis. The patient is approved for 9 hours a day, 7 days per week (63 hours per week) of Personal Care Services. The patient and her care team requested an increase to 24 hours per day, 7-days per week live-in (total 91 hours per week).
A letter of medical necessity for this appeal was provided by the treating physician. The physician states that the patient has had a rapid physical and functional decline. She has urinary incontinence and requires multiple diaper changes throughout the day and night. She requires human assistance for nearly all activities of daily living (ADLs) and transfers. The physician feels that 24 hour per day personal care is medically necessary for the patient. 

A Uniform Assessment System (UAS) was completed and was available for review. The patient was cognitively intact with some difficulty in new situations only. From a functional standpoint, she requires total dependence for housework. She requires maximal assistance for meal preparation. She requires extensive assistance for shopping, transportation, and stairs. She requires limited assistance for finances and medications. For her ADL's, she requires maximal assistance for bathing, dressing lower body, and toilet use. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and bed mobility. She requires limited assistance for eating. It was noted that the patient has had difficulty with ADL's since being discharged from a nursing facility; family has been checking in on her but cannot do enough to meet her needs, and they have been paying out of pocket for nighttime help. She is frequently incontinent of both urine and stool and wears pull-ups for incontinence care. She has no pressure ulcers. An Hours Evaluation for Paraprofessional Support (HELPS) assessment associated with the UAS recommended 43 hours per week to address her functional needs. The subject under review is the medical necessity for the increase in personal care services (PCS) to 24 hours a day, 7 days a week (live in) for a total of 91 hours per week. 

The requested increase of hours for Personal Care Services (PCS) 24 hours a day, 7 days a week (live-in) for a total of 91 hours is medically necessary for this patient. The patient is unable to perform any ADL's or Instrumental activities of daily living (IADLs) independently. She has been rapidly declining from a physical and functional standpoint according to the treating physician. Furthermore, she has incontinence of stool and urine. She cannot address her toileting needs independently, and thus it is medically necessary for her to have personal care throughout the day and night. She cannot schedule her personal care hours to allow them to be done during the time the aide is currently present as these needs are, by definition, unscheduled. The family has been covering this gap by paying out of pocket for her nighttime personal care needs, and if they cannot continue this it would be detrimental to the patient. Failure to address her toileting needs and diaper changes in a timely manner could result in skin breakdown and/or infections. It is therefore medically necessary to increase her hours to the requested services. Live in is appropriate as it would be reasonable to expect the aide to be able to get sleep when not addressing toileting needs.