Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's Disease.
Treatment:  Home Health Care (increase in Personal Care Assistance (PCA) hours).

The health plan denied the request for an increase in PCA hours.  The health plan's determination is overturned.

The patient is a male with a past medical history of dementia, Parkinson's disease, hypertension, diabetes mellitus type 2, benign prostatic hyperplasia (BPH), gout, urinary incontinence, aortic valve stenosis, chronic kidney disease, osteoporosis, and osteoarthritis, who had an assessment tool performed with a task sheet calculating personal care assistance (PCA) hours per week of 49 hours.  At that assessment the patient was assessed at total assistance for tasks of meal preparation, ordinary housework, shopping, transportation, bathing, dressing lower body, and locomotion while assessed at maximal assistance with tasks of managing finances, managing medication and stairs.  The patient was assessed at extensive assistance with tasks of personal hygiene, dressing upper body, walking, transfer toilet, toilet use, bed mobility, and eating, while assessed at limited assistance with phone use. 

The visiting nurse and physical therapist (PT) reassessed and noted the patient needs assistance from daughter for transfers and ambulation and needs assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and personal care.  The PT note specifically stated the patient needed assistance with toilet, tub/shower, bed to chair, transfers, and bed mobility.  The patient had a return assessment with tasking tool calculating 45.5 hours/week, and the patient was assigned PCA services 63 hours/week.  The patient later had a telephonic assessment tool performed, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, shopping and transportation while maximal assistance with tasks of managing finances, managing medication, stairs, bating, personal hygiene and dressing upper/lower body.  The patient was assessed at extensive assistance with tasks of walking, locomotion, transfer toilet, toilet use, bed mobility, and eating while limited assistance with phone use.  This assessment noted the patient's ADL performance status declined.  At issue is the medical necessity of the requested increase in PCA hours.

The health plan's determination of medical necessity is overturned, in whole.

Yes.  The patient has progressive medical conditions of Parkinson's disease and dementia, which will worsen with time.  The patient had a hospitalization with noted assistance needs in his home PT notes.  The patient was unable to walk without assistance and requires assistance with all ADLs.  The patient's later assessment noted the patient to need total assistance with tasks of bathing and dressing lower body but was reported as maximal assistance at the later assessments, which would not be explained by supporting documents, as it has been noted the patient has had worsening physical functioning.  The patient requires assistance with unpredictable and unscheduled needs such as walking, locomotion, transfer toilet, and toilet use and would need the assistance of a PCA outside the hours that his informal helpers are not available.  PCA service hours are not solely for supervision and safety but to assure safe completion of ADL and IADL tasks.  Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in their own home.