Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Personal Care Aide (PCA) Level 2; 24 hours live in services, 7 days per week
The insurer denied the Personal Care Aide (PCA) Level 2; 24 hours live in services, 7 days per week.
The determination is overturned.

The patient has a past medical history of hypertension, hyperlipidemia, anemia, schizoaffective disorder, Parkinson's disease, chronic kidney disease (CKD), cerebrovascular accident (CVA), gastrointestinal (GI) bleed, pancytopenia, urinary incontinence, and bowel incontinence who had been assigned personal care assistant services (PCA) services 35 hours/week based on an assessment tool performed via telephone assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, stairs, shopping, and transportation while extensive assistance with tasks of managing finances, managing medication, bathing, dressing upper/lower body, and toilet use. The patient was assessed at limited assistance with tasks of phone use, personal hygiene, walking, locomotion, transfer toilet, bed mobility, and eating. There was a request to increase the PCA services and the patient underwent another telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, and equipment management while maximum assistance with tasks of managing medication, bathing, dressing lower body, walking, locomotion, and toilet use. The patient was assessed at extensive assistance with tasks of phone use, dressing lower body, transfer toilet, bed mobility, and eating while limited assistance with task of personal hygiene.
Notes from this assessment stated the patient was unable to prepare meals, was unable to stand long periods of time, had bilateral hand tremors, finances were managed by her sister, was unable to get medicine out of weekly pack due to tremor, was assisted to standing and taken into the bathroom with contact guard and use of walker, could not participate in bathing, could push herself up and down from the toilet once she was assisted by walker and aide to the bathroom, needed to support herself on the walker while being cleaned and redressed, was incontinent of bowel and bladder and needed help changing pullups and incontinence pads, needed physical assistance to get in and out of bed, was unable to complete a meal and needed to be fed, was usually in recliner or wheelchair and was unable to wheel herself, and the patient's family was paying privately for aide services when the PCA was not present.
The patient had an office visit with her primary care physician (or provider) (PCP) with note of self care deficit, unable to care for self at home, needed additional home health aide hours, was unable to walk, was using wheelchair and walker, needed assistance with transfers, was unable to bath, dress, toilet, cook, clean or feed herself, was left alone for 16 hours per day, and was incontinence of urine and stool. The PCP office note also stated the patient was unable to stand more than 30 seconds, was wheelchair bound, lived alone, requested physical therapy (PT) / occupational therapy (OT) for strength training, was unable to sit up straight in her wheelchair, and that the PCP would contact the patient's case manager for request for additional aide hours.
The plan sent an initial adverse determination denial notice stating the request was partially denied with an increase in PCA hours to 49 hours/week. The plan sent a final adverse determination notice stating PCA services would stay at 49 hours/week as the requested increase was not medically necessary. The denial stated the plan does not provide PCA hours for safety monitoring, supervision, and cognitive prompting. The plan further stated the patient could split her hours to meet her needs. The patient's neurologist provided a letter stating the patient has extensive psychiatric, neurologic, and medical problems that have rendered her unable to care for herself. The note further stated the patient was totally unable to care for herself, was unsafe to be alone, was dependent on others for all mobility related to activities of daily living as well cannot manage access to nutrition or hydration, and required care 24 hours/day, 7 days/week. The patient was seen by her PCP  and the office note stated the patient needs additional home health aide hours, was unable to walk, needed assistance with transfers, was at high risk for impaired skin integrity due to prolonged periods when unable to change soiled depends, and needed 24 hour aide services.
The PCP provided Department of Health (DOH) 4359 stating the patient had weekly wound care, was unable to walk/sit unassisted, unable to ambulate, stand, pivot, sit, and was wheelchair/bed bound. The form further stated the patient's family member was unable to provide care as the family member was disabled. The patient's sister provided a letter stating she was not longer able to provide informal support to the patient and listed the patient's multiple care needs. The patient's health care advocate provided a letter requesting an expedited appeal for the patient for coverage of 24 hour/day, live-in PCA services 7 days/week. This letter further outlined the patient's medical diagnoses, the patient's functional ability, the assessments and subsequent denial for increase in PCA services, and the medical necessity for increase in requested PCA services. The insurer sent a summary of events regarding the Uniform Assessment System (UAS) performed and subsequent decision for PCA service hours. At issue is the medical necessity of Personal Care Aide (PCA) Level 2; 24 hours live in services, 7 days per week.
The services are medically necessary.
The patient has documented chronic progressive medical conditions. The patient's PCP and neurologist documented these diagnoses and progressive decline in functional and mental status. The patient needs assistance with all activities of daily living (ADL) /instrumental activities of daily living (IADL) tasks. The patient has unscheduled and unpredictable care needs over a continuum of time and the insurer failed to document a plan to meet these care needs. The patient's informal caregiver is unable to continue to provide care due to her own medical diagnoses. The patient requires assistance with walking, locomotion, transfer toilet, toilet use, and incontinence cares. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's increase in care needs cannot be met alone with medical equipment and supplies. 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, PCA services 24 hours/day, live-in, 7 days/week, are medically necessary for this patient. 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 her own home.