Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease

Treatment: Personal care aide (PCA) services 8 hours per day, 6 days per week, for a total of 48 hours per week

The insurer denied coverage for personal care aide (PCA) services 8 hours per day, 6 days per week, for a total of 48 hours per week.

The denial is overturned.

The patient is an adult who lives with their spouse. The patient is noted to have a diagnosis of Parkinson's disease, anxiety, depression, chronic fatigue, dependence on wheelchair, essential (primary) hypertension, functional urinary incontinence, hyperlipidemia, hypothyroidism, hypocalcemia, dry eye syndrome, insomnia, nightmare disorder, generalized muscle weakness, other muscle spasm, paresthesia of skin, and unspecified abnormalities of gait and mobility. Current medications include carbidopa-levodopa, clonazepam, gabapentin, levothyroxine, losartan potassium, mirtazapine, Osmolex extended release (ER), Rytary, simvastatin, Sinemet, Tylenol, Claritin, multivitamin, lutein, calcium plus D3, Coenzyme Q10 (CoQ10), probiotic, Omega-3 fatty acids, and vitamin C. 

The patient is independent with decision making and has intact memory. The patient is totally dependent with housework and meal preparation. The patient requires maximal assistance with shopping. The patient requires extensive assistance with bed mobility, toilet use, dressing, bathing, and hygiene. The patient is frequently incontinent of bladder and is continent of bowel. It was reported that the patient falls 1-2 times weekly, has a normal mode of nutritional intake, and ambulates with a walker and wheelchair. No hospitalizations were noted in the last 90 days. 

According to the Task Assistance Tool, 34 hours of formal support is needed per week to meet the patient's needs. It was reported that 6.5 hours of assistance is needed per week for meal preparation, 1 hour of assistance is needed weekly for shopping, 2 hours of assistance is needed weekly for bathing, 3 hours is needed weekly for toileting, 2 hours of assistance is needed weekly for transfers, and 2.5 hours is needed weekly for ambulation. 

An undated external appeal application signed by the patient's spouse stated that the patient has had a change in their health status and requires an increase in care hours to 8 hours daily. It was stated that the patient falls very often, is unable to walk at times, and requires the use of a wheelchair more frequently. The patient's spouse stated that the patient is also incontinent of bowel and is unable to clean themselves, occasionally hallucinates, has difficulty remembering to take medications and use their walker, and has difficulty ambulating. The patient's spouse stated that they have a heart condition and recently underwent eye surgery, resulting in double vision, and due to their heart condition, it is not good for them to attempt to lift the patient.

The patient has demonstrated a recent decline in function. The patient is stated to have experienced a decline in health and function, resulting in bowel incontinence, occasional hallucinations, difficulty ambulating, and an increased need for wheelchair use. Additionally, the patient is noted to be at risk for falls, and has difficulty remembering to use their walker. As such, the denial of personal care aide (PCA) services 8 hours per day, 6 days per week, for a total of 48 hours per week is overturned, as the request is medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care aide (PCA) services 8 hours per day, 6 days per week, for a total of 48 hours per week is substantiated.