Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's disease, memory loss, degenerative joint disease, osteopenia.
Treatment:  Increase Personal Care Services, 8 to 10 Hours per Day, 7 Days per Week.

The insurer denied the Increase Personal Care Services, 8 to 10 Hours per Day, 7 Days per Week.  The denial is overturned. 

This patient is a female with several chronic medical conditions, including Parkinson's disease, memory loss, degenerative joint disease (DJD), osteopenia, irritable bowel syndrome (IBS), and constipation.  The patient lives alone.  The patient was admitted to an inpatient level of care after a fall; she was transferred to a skilled nursing facility (SNF) and later discharged.  The patient states more help is needed after skilled nursing facility (SNF) discharge and is appealing the request to increase personal care services (PCS) from 30 to 70 hours per week.  

An assessment performed shows functional status: max assistance with housework; extensive assistance with meal preparation, transportation, bathing, and lower body dressing; limited assistance with managing finances and medications, personal hygiene, upper body dressing, walking, locomotion, toileting, and bed mobility; and independent with phone use and eating.  She has infrequent bladder incontinence.  The patient has equipment including a walker, cane, shower chair, grab bars and personal emergency response system.  A bedside commode is recommended.  An appeal statement notes that the patient's current aid works from 9 a.m. to 3 p.m., but she needs help at night with dressing, walking, transferring, toileting, shopping, laundry, meals, and bathing.  She is now experiencing freezing of gait.  A statement from the doctor notes that the patient has advancing Parkinson's disease and lumbar stenosis as well as bilateral hip pain.  The patient has dramatic progression in gait instability resulting in frequent falls.  She increasingly needs the assistance of a caregiver for transfers with her walker.  Difficulty with transfers, tremors and lack of coordination affect the patient's ability to perform activities of daily living (ADLs).  The patient was hospitalized several times after falls.  Request was made for an increase in hours after discharge from nursing home.  The patient is recommended to continue with in-home physical therapy (PT) / occupational therapy (OT).  The provider notes that escalating pain medications increases risk for falls; limiting fluid intake is unsafe due to hypotension. 

There are several appeal letters.  A letter from the doctor states the patient's chronic conditions result in severe debility and difficulty leaving home.  Another provider submitted a statement which states the patient's chronic medical conditions are worsening.  She has progression in tremors and gait instability resulting in frequent falls.  She has increasing needs for assistance with transfers.   She had falls in the bathroom that resulted in hospitalization.  There was no change in personal care service (PCS) hours after the initial fall.  A statement dated from another provider recommends ten hours of home care due to need with all activities of daily living (ADLs) during waking hours.

Yes, the proposed treatment is medically necessary.

Medically necessary services are those which are:  1) safe, 2) effective, 3) generally accepted national standard of medical practice, 4) not provided primarily for convenience of the patient or the practitioner, and 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested personal care services (PCS) for 70 hours per week are 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.  

This patient was approved for 30 hours based on two assessments.  This assessment shows the patient needs assistance with housework, meal preparation, transportation, bathing, dressing, and walking.  The patient has a walker, cane and shower chair.  A bedside commode was recommended.  Since the first assessment, the patient was hospitalized twice after falls.  Appeal letters and reports provided after hospitalization show that the patient's Parkinson's is progressing.  The patient has more tremors and a decline in gait stability.  Other than phone use and eating, the patient requires max assistance with activities of daily living (ADLs) and personal care throughout the day.  Mobility limitations make the patient an increased fall risk when she tries to transfer and ambulate to the bathroom.  Based on progression of this patient's Parkinson's disease resulting in increased need for assistance throughout the day, the 30 personal care service (PCS) hours per week are no longer sufficient to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care.  The proposed increase in personal care service (PCS) hours to 70 per week is medically necessary for this patient.