Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, cerebrovascular accident (CVA) with right-sided weakness, diabetes mellitus.

Treatment personal care assistance (PCA) services of 12 hours per day, 7 days per week for a total of 84 hours per week.

The insurer denied coverage for personal care assistance (PCA) services of 12 hours per day, 7 days per week for a total of 84 hours per week.

The denial is overturned.

The patient is a female with a past medical history of Parkinson's disease, cerebrovascular accident (CVA) with right-sided weakness, diabetes mellitus, cervical spondylosis, thoracic spondylosis and spinal stenosis. Per the uniform assessment system (UAS), the patient had personal care services 7 days a week 7 hours/day. The patient was wheelchair dependent. The patient was alert and oriented to person, place an time. The short-term memory was a problem, and the procedural memory was okay. The patient was modified independent with some difficulty in new situations only. The patient was self-directing and could make decisions for activities of daily living (ADLs). The patient had clear comprehension and expressed readiness without difficulty. The patient had total dependence for meal preparation, shopping, using stairs, transportation, ordinary housework, toilet transfer and toilet use. The patient was maximal assistance for managing finances. She would help throughout the task but performed less than 50% (percent) of the tasks on her own. She required maximal assistance for performance of ADLs including bathing, dressing her lower body, and bed mobility. She required extensive assistance for managing medications. She helped throughout the task but performed 50% or more of the task on her own. The patient required extensive assistance for managing personal hygiene and dressing her upper body. The patient was frequently bowel and bladder incontinent and used pull-ups and diapers for incontinence. The patient needed supervision for oversight/cueing for eating.

The letter noted that some of the patient's conditions had deteriorated. The patient suffered from cervical spondylosis, thoracic spondylosis and spinal stenosis. The conditions had worsened in the past year and the patient had much difficulty standing and walking. The provider requested an increase from 7 to 12 hours/day to allow the patient and her family to monitor and assist the patient with her daily activities including meals, appointments, and other errands that she may require. 

This woman who is said to require increasing assistance with her ADLs including personal hygiene and supervision with eating. She is at increased risk for falls due to reported severe osteoarthritis of her spine, previous CVAs with deficits and Parkinson's disease. She would benefit from an increase in PCA hours from 7 hours a day to 12 hours a day due to reported progression of her underlying conditions and decreased mobility.

Based on the review, there was sufficient evidence to support that 84 hours a week of PCA services was considered medically necessary treatment for the patient's condition.

The health care plan did not act reasonably and with sound medical judgment or in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Assistance (PCA) Services of 12 hours per day, 7 days per week for a total of 84 hours per week is reversed. Medical necessity is substantiated.