Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
 
Treatment: Increase in personal care service

The insurer denied coverage for increase in personal care service hours from 25 hours to 40 hours per week. The denial is reversed. 

This patient is a female with substantial functional impairment as a result of Parkinson's disease, orthostatic hypotension, gait abnormality, muscle weakness, stress incontinence, varicose veins of lower extremities with pain. She is receiving personal care services (PCS) 25 hours per week (5 hours per day x 5 days per week). Her daughter provides help on the weekends. The patient requested increase of PCS to 40 hours per week, which was denied. 

Parkinson's disease (PD) is a progressive neurologic disorder that affects motor function, causing tremors, bradykinesia, rigidity, abnormal gait, postural instability, speech and swallowing problems. Non-motor effects of PD include cognitive impairment, hallucinations, mood disorders, sleep disorders, pain/cramps, constipation, blood pressure fluctuations including orthostatic hypotension, fatigue. There are various medications to manage the motor symptoms of PD. The primary drug is carbidopa-levodopa which is generally necessary for patients with at least moderate severity of symptoms. 

Other drugs may be useful alone in the earlier stage of PD and some drugs can have additional effect with carbidopa-levodopa to manage symptoms in later stages. Non-motor symptoms can be challenging to manage, and need to be addressed individually. Management of motor symptoms with carbidopa-levodopa changes as the symptoms progress. When carbidopa-levodopa is working effectively, the patient has improved mobility, tremors decrease, gait improves. However, when the effect of the drug wears off, the patient can experience significant decline in function until the next dose takes effect.
The UAS indicates the patient needs maximal assistance for household related tasks. For ADLs, she needs extensive (weight-bearing) assistance for bathing, transfers, walking, and all toileting related activities. Most of the patient's household tasks and morning ADLs (bathing, dressing, and hygiene) can be managed adequately with PCS 5 hours per day, including preparation of 2 meals. However, the patient has difficulty with ambulation, transfers and toileting, which occur beyond 5 hours per day. 

Mobility problems can have various adverse effects on the patient's daily function, health and safety. When the patient is alone and has difficulty moving around her home, she may be reluctant or fearful to engage in various activities around the house, especially as she has had falls in the past. Falls are a common and serious problem for people with PD and can be associated with substantial morbidity. As a result of Parkinson's disease, the patient has significant functional impairment that requires assistance for safe and proper performance of daily activities. Therefore, it is medically necessary for the patient to have caregiver assistance for an extended period of the day when most of her daily activities occur. Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services. The patient has only one informal caregiver, i.e. her daughter who can provide care on the weekends. Therefore, without an informal caregiver who can provide consistent hours of care each day, then personal care services are indicated to provide the necessary assistance with ADLs and IADLs.

Personal Care Services 40 hours per week are medically necessary. The health care plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for an increase in personal care service hours from 25 hours to 40 hours per week is substantiated.  The insurer's denial is reversed.