Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Parkinson's disease
Treatment: Home Health Care-PCA services
The health plan denied the increase in PCA services to PCA Level 3 Services for the total amount of 168 hours per week, split shift, as not medically necessary. 
The reviewer has overturned the health plan determination in whole.  

The patient has a past medical history of Parkinson's disease, Alzheimer's disease, hypertension, gastroesophageal reflux disease (GERD), depression, anxiety, urinary incontinence, bowel incontinence, dysphagia, hypoxia with oxygen use, osteoporosis, and osteoarthritis of multiple joints who had been assigned personal care assistant (PCA) services 11.5 hours/day, 7 days/week to total 80.5 hours/week based on an assessment tool. The patient had a hospitalization for aspiration pneumonia with respiratory failure and was discharged back to home on hospice. The hospice admission notice stated the patient was on thickened liquids, was wearing oxygen continuously, and among other activities needed help with turning and positioning every 2 hours. 

There was an assessment tool performed via telephone. The Registered Nurse from the assessment notes that the patient was unable to recognize goals, has unclear speech, was unable to answer questions other than yes or no, was unable to hold a spoon, and needed arm lifted by another to drink liquids. The patient was then approved for PCA services 24 hours/day, live-in, 7 days/week. The patient's daughter provided a letter  that the patient's personal care needs now exceed the daughter's abilities due to  worsening status following the recent hospitalization for aspiration pneumonia putting a serious toll on the daughter's physical and emotional health, as well as personal and professional life. The patient's primary care provider specifically requested an increase in PCA hours to 24 hours/day, two split-shifts, 7 days/week. The provider further states the patient is bedbound and requires total assistance with all activities of daily living, including bathing, dressing, grooming, skin care, toileting, turning and repositioning in bed every two hours, oxygen monitoring, preparation of pureed meals and thickened liquids, and administration of medication. The patient's healthcare advocate provided a letter stating the rationale for requested PCA services. The advocate further documents the patient's unscheduled nighttime needs would not allow a PCA to obtain 5 hours of uninterrupted sleep.

The increase in PCA Level 3 Services for the total amount of 168 hours per week are medically necessary for this patient.

There is documentation of the patient's chronic medical conditions which have worsened and progressed with further decline in physical and mental functioning following a hospitalization for acute respiratory failure and aspiration pneumonia. The patient requires assistance with all activities of daily living and instrumental activities of daily living. The patient's informal caregiver is no longer able to provide care in the overnight hours due to her own personal and medical issues. The patient requires 24 hour care. The patient has unscheduled and unpredictable care needs over a continuum, specifically nighttime needs that are unpredictable and would not allow a PCA to obtain 5 hours of uninterrupted sleep. The patient's hospice plan and her primary care physician indicate the patient requires assistance with turning and repositioning every 2 hours. 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.