Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: Increase in Personal Care Worker to 7 days per week, 24 hours per day, continuous care by more than one person
The insurer denied the increase in Personal Care Worker to 7 days per week, 24 hours per day, continuous care by more than one person.
The denial is overturned. 

The patient is a male with reported deteriorating physical and mental health. He has advanced Parkinson's disease as well as MDD (major depressive disorder) and severe anxiety. He is unable to complete ADLs (activities of daily living) independently. The patient has an adjustable hospital bed, urinal, bedside commode, and incontinence supplies. The patient has difficulty sleeping at night but is noncompliant with Ambien. 

Assessment performed showed the patient's level of functioning has changed to requiring more assistance with ADLs. He was able to transfer from bed to wheelchair with PCW assistance. The patient ambulates with walker and assistance at times but has not ambulated for days due to pain. His primary mode of locomotion is wheelchair. He requires max assistance with dressing, locomotion, and toileting. The patient uses urinal with assistance. 

A statement from the provider states that there is rapid decline in the patient's cognitive, physical and functional health. The patient is unable to perform ADLs and the patient requires assistance with reminders, preparation, and administration of medications and meals. Also, the provider states that the patient requires assistance with bed and wheelchair mobility and movement along with bihourly turning to prevent pressure ulcers. The patient is requesting an increase in PCW services from live-in Level 1 PCW to continuous care. 

Yes, the increase in Personal Care Worker to 7 days per week, 24 hours per day, continuous care by more than one person is medically necessary.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs, including toileting, walking, transfers, turning/positioning, and feeding. Personal care service is necessary when assistance cannot be met from use of from informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split-shift personal care is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to provide five hours daily of uninterrupted sleep during the aide's eight hour period of sleep. 

This patient has a rapidly progressive condition with assessment performed showing deterioration over several months. He is dependent with ADLs. Per the statement from the provider two months after the assessment, the patient now requires bihourly turning to prevent pressure ulcers. The medical records and accompanying information provided do support the medical necessity for continuous care. The patient requires assistance with ADLs as well as bihourly turning that cannot be managed with Level 1, live-in PCW.