Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease.

Treatment: Level 1 Personal Care Worker service 7 days per week, 10 hours per day, 70 hours per week

The insurer denied coverage for Level 1 Personal Care Worker service 7 days per week, 10 hours per day, 70 hours per week.

The denial is overturned.

According to the documentation submitted, this male patient has a medical history of Parkinson's disease, hip fracture, constipation, generalized pain, hyperlipidemia, hypertension, prostate and bladder cancer, hypothyroidism. The patient was discharged from rehabilitation center and per the discharge planning instructions, the patient required one-person assistance for bed transfers, ambulating, using the toilet, dressing and taking medications. Supervision was required for eating and personal hygiene. The patient was to return home with skilled nursing, physical therapy and home health aide services. The request is for Level 1 Personal Care Worker (PCW) services 7 days per week, 10 hours per day, 70 hours per week.

According to the Uniform Assessment System (UAS) performed and the problems encountered by patients with advanced Parkinson's disease, arthritis and depression, it is medically necessary for the patient to have caregiver assistance to properly and safely move around his home and complete daily activities. Assistance is necessary in order to decrease the risk of adverse health and safety events (e.g. falls/injury, skin damage, malnutrition, dehydration).  ADLs such as transfers, walking, toileting/incontinence care are not scheduled tasks and occur at various times throughout the day. The level of assistance needed also may change during the day due to the variability of the patient's level of function throughout the day due to Parkinson's disease. 

The available records do not identify informal caregivers who are providing assistance to the patient on a regular basis. The UAS identified 2 informal caregivers, but it does not appear that they provided care on a daily basis. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. Without informal caregivers who can provide care on a consistent basis when needed, then personal care services are indicated to provide assistance with daily activities, including ADLs that occur throughout the day. The patient is currently receiving PCW services 6 hours per day, 42 hours per week. This is not sufficient to address all the patient's ADL needs each day, including transfers, walking, toileting, incontinence care, and evening ADLs (dinner, evening change of clothes, personal hygiene). The request for increase of PCW services is for 10 hours per day, 70 hours per week. This still raises concern for the night hours. If the patient needs to get out of bed at night for toileting or other reasons he is without assistance, increasing his risk of falls. If the patient is incontinent at night, he needs assistance, as he should not remain in soiled diapers/pads for extended hours. The maximal number of hours that can be approved from this review is limited by the hours requested, i.e. 70 hours per week. 

Level 1 Personal Care Worker service 7 days per week, 10 hours per day, 70 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for Level 1 Personal Care Worker (PCW) services, 7 days per week, 10 hours per day (70 hours per week) is substantiated.  The insurer's denial is overturned.