Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's Disease
Treatment: Increased PCA service hours 24 hour/day, split-shift, 7 days/week, to total 168 hours/day.
The insurer denied the increased PCA service hours 24 hour/day, split-shift, 7 days/week, to total 168 hours/day.
The determination is overturned.

This patient with a past medical history of prostate cancer, Parkinson's disease, depression, anxiety, spinal stenosis, benign prostatic hyperplasia (BPH), urge incontinence, orthostatic hypotension, coronary artery disease and hyperlipidemia had been assigned PCA services 24 hours/day, live-in, 7 days/week to total 168 hours/week. The patient lives with his wife who also receives personal care aide (PCA) services. The patient had three falls and was hospitalized with subsequent transfer to rehabilitation with discharge to home. There was a request to increase PCA service hours by changing to 24 hour/day, split-shift, 7 days/week, to total 168 hours/day.
The patient had an assessment tool performed documenting total assistance needs for tasks of meal preparation, ordinary housework and stairs while assessed as maximal assistance with tasks of managing finances, managing medication, shopping, transportation, bathing, dressing lower body and toilet use. The patient was assessed as requiring extensive assistance with tasks of phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet and bed mobility while assessed at limited assistance with task of eating. The assessment tool noted the patient was very forgetful and confused at times. The patient's PCP wrote a letter stating the patient is unable to ambulate independently due to spinal stenosis and rapidly progressive Parkinson's disease symptoms, has autonomic instability increasing fall risk due to low blood pressure, is unable to sleep through the night due to urinary frequency with perceived need to urinate every 8-10 minutes, is unable to void while supine due to BPH and requires assistance to stand from bed and is having increased delusions secondary to Parkinson's disease.
The patient's neurologist wrote a letter stating that changes in his medical condition should warrant 2 x 12/7 PCA care, that he needs total personal care assistance with all activities of daily living (ADLs), that his urologic condition causes him to have urinary urgency and frequency with need with help to get to bathroom multiple times day and night and an increase in hallucinations causing him to need help getting up out of bed. There was a letter from the patient's psychiatrist stating the patient had dementia and anxiety with the need for help with ADLs including medication administration to help with controlling his symptoms. This provider specifically requested two split shift of 24 hour care, 7 days/week. The patient's daughter wrote a letter further outlining the risks to his health and ability to live at home without PCA services 24 hour/day, split-shift, 7 days/week. In addition, the patient's physician grand-daughter wrote a letter stating worsening Parkinson's limiting his ability to get out of bed or get up from a chair or toilet. It also stated the patient has an inoperable bladder stone and BPH causing him to experience urinary urgency and frequency with the need for help with getting out of bed, toileting and transfer toileting every 20-30 minutes overnight. There is a letter from the home care agency stating patient is in constant need of using the bathroom and falls if left unattended. The agency also noted they have a hard time staffing the case as many aides have quit due to the inability to sleep as the patient requires frequent assistance overnight. The patient's primary care physician (or provider) (PCP) again wrote a letter stating the patient needs PCA services on 2-12 hour shifts due to his constant need for assistance with ambulation, maintaining activities of daily living as well as psychosocial support to manage his delusions. There was a final adverse determination from the insurerdenying the request to increase PCA services hours from 24 hours/day, live-in to 24 hours/day, split-shift. At issue is the medical necessity of personal care aide services - live in per diem increase to 24 hour(s) per day (split shift).

Yes, the requested services are medically necessary. There is documentation from the patient's primary care physician on 2 occasions that the patient has significant urinary urgency and frequency causing him to need to use the bathroom every 8-30 minutes. There is corroboration with the home care agency regarding these facts. Because of his BPH and inoperable bladder stone, his PCP notes, that he must be standing in order to urinate, and requires assistance with getting out of bed, transferring, ambulating and toileting. His needs to urinate multiple times overnight which would not allow for a PCA to obtain at least 5 hours of uninterrupted sleep. The patient's overnight PCA needs are not for supervision and safety alone. It is medically necessary for the patient to have split shift 24-hour per day, 7 day per week PCA services.