Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Parkinson's Disease
Treatment: Home Health Care
The health plan denied the request for an increase in personal care hours as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with a past medical history of Parkinson's disease, osteoporosis, osteoarthritis, spinal stenosis, age-related cognitive decline, hypertension, bladder cancer, deep vein thrombosis, atrial fibrillation on chronic anticoagulation, urinary incontinence, gastroesophageal reflux disease (GERD), and peripheral vascular disease (PVD) who had been assigned personal care assistant (PCA) services 6 hours/day, 4 days/week, to total 24 hours/week based on assessment tool. At the assessment, the patient was assessed at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing medication, stairs, transportation, equipment management, bathing, and dressing upper/lower body. With tasks of managing finances, phone use, personal hygiene, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating the patient was assessed at limited assistance. Notes from the assessment stated the patient lived with her husband and he provided informal support.

The health plan's determination of medical necessity is overturned, in whole.

The patient has documented progressive medical conditions of Parkinson's disease, osteoarthritis, and age-related cognitive decline. There is documentation of worsening of the patient's activities of daily living (ADLs) status and functional status per the assessment and the patient's neurology provider. The patient did have informal help with her spouse who lived with her, but he died. The patient requires at least some assistance with all ADLs/instrumental activities of daily living (IADLs). The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these needs when informal help was not available. The plan's denial letter stated the patient was able to walk, transfer, and use the toilet with the help of assistive device, walker, but the patient's neurologist's letter indicated the patient's bathroom is not able to accommodate the patient's walker. The patient's care needs cannot be safely met solely with medical supplies and adaptive equipment. The patient had participated with physical and occupational therapy in the past. The increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. 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 12 hours/day, 7 days/week, to total 84 hours/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.