Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's Disease
Treatment: Home Care/Personal Care Level 2 Personal Care Services: 2 days CDPAS split shift.
The insurer denied Home Care/Personal Care Level 2 Personal Care Services: 2 days CDPAS split shift.
The determination is upheld.

The patient is a female with a past medical history of macular degeneration, osteoarthritis, Parkinson's disease, dementia, bladder incontinence, chronic obstructive pulmonary disease (COPD), coronary artery disease, atrial fibrillation, diabetes mellitus type 2, hearing loss, and lymphedema who had been provided Personal Care Aid (PCA) services 9 hours/day, 7 days/week based on assessment performed assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, shopping, and dressing lower body. With tasks of managing finances, managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper body, walking, locomotion, transfer to the toilet, and toilet use the patient was assessed at extensive assistance. There was a request to increase home health services and the patient underwent a telephonic assessment on assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, shopping, transportation, equipment management, bathing, personal hygiene, dressing upper/lower body, transfer to the toilet, toilet use, and eating while maximum assistance with tasks of phone use, stairs, walking, locomotion, and bed mobility. Tasking tool estimated 61.67 hours/week.
The patient's neurologist provided a letter noting the patient's diagnoses and due to her Parkinson's disease, the patient experienced rigidity, weakness, freezing episodes, difficulty ambulating, falls, and required total assistance with her activities of daily living (ADL)s including bathing, dressing, feeding, and ambulation. The provider also noted the patient required assistance with transfers in and out of the bed and to the toilet and the patient woke up throughout the night and required toileting. The letter also stated the provider was requesting split shift 24-hour care to ensure the patient's wellbeing, safety, and hygiene.
The insurer approved PCA services 24 hours/day, 7 days/week, live in.
At issue is the medical necessity of Home Care/Personal Care Level 2 Personal Care Services: 2 days Consumer Directed Personal Assistance Program (CDPAS) split shift.

The requested health service/treatment of Home Care/Personal Care Level 2 Personal Care Services: 2 days CDPAS split shift is not medically necessary for this patient.
Per the documentation, the requested service is not medically necessary. There is no documentation provided of the medical necessity of split shift services. Specifically, there are no overnight care logs documenting specific care needs and specific timing of ADL assistance needs in the overnight hours that would not allow a PCA 5 hours of uninterrupted sleep. There is no documentation of the medical necessity of turning and repositioning every 2 hours. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 48 hours/week (2 days CDPAS split-shift) are not medically necessary for this patient.