Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease, Dementia
Treatment: Personal care aide (PCA) level 2: 12 hours per day- 7 days per week; consumer directed personal assistance program (CDPAP): 12 hours per day- 7 days per week (split-shift) - a combined total of 168 hours per week.
The insurer denied Personal care aide (PCA) level 2: 12 hours per day- 7 days per week; consumer directed personal assistance program (CDPAP): 12 hours per day- 7 days per week (split-shift) - a combined total of 168 hours per week.
The determination is overturned.

This is female patient with a medical history notable for Parkinson's disease and dementia. The patient is currently approved for 24 hours per day live-in, 7 days per week of personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week), and this request was denied by the insurance company.
A letter of support for this appeal was provided by the patient's physician. The letter states that the patient this bed bound and fully reliant on others for her care. It states that "ideally she would benefit from a 12 split-shift to better support her care" and that it would "improve her quality of life and care at night because she suffers from insomnia, anxiety, hallucinations and can receive the attention that she needs."
A Uniform Assessment System (UAS) was completed and was available for review. The patient's daughter, personal care worker, and consumer-directed personal care aide were present for the evaluation. The patient lives alone. Her cognition was moderately impaired. She was alert and oriented to person only. By family report, her level of awareness is waxing and waning. Recall was 0/3 at five minutes and the patient cannot direct her own care. She does not respond to questions when asked. For her Instrumental activities of daily living (IADLs), she requires total dependence for all. For her activities of daily living (ADLs), she also requires total dependence for all. She is not able to stand or ambulate even with assistance. She is incontinent of stool and urine with no control present and is not able to tell the family when she needs to toilet. At issue is the medical necessity of personal care aide (PCA) level 2: 12 hours per day- 7 days per week; consumer directed personal assistance program (CDPAP): 12 hours per day- 7 days per week (split-shift) - a combined total of 168 hours per week.

The requested health service of personal care aide (PCA) level 2: 12 hours per day- 7 days per week; consumer directed personal assistance program (CDPAP): 12 hours per day- 7 days per week (split-shift) - a combined total of 168 hours per week is medically necessary for this patient.
The patient has advanced dementia and cannot direct her own care. She has incontinence of stool and urine and is completely aware of when she needs to void or have a bowel movement. She will require continuous hands-on personal care to meet her functional needs. A live-in personal aide is required to have at least 5 hours of uninterrupted sleep at night. This patient will likely continue to require care that would preclude this window of uninterrupted sleep for the aide. She cannot be left alone in a soiled diaper for 5-8 hours each night as it could lead to skin breakdown and/or infection. She also requires others for bed mobility and will require assistance to prevent skin breakdown.