Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease.
Treatment: CDPAP services 24 hours/day, split shift, 7 days/week, to total 168 hours/week.
The insurer denied CDPAP services 24 hours/day, split shift, 7 days/week, to total 168 hours/week.
The determination is overturned.

The patient has a past medical history of Parkinson's disease, postural instability, constipation, anxiety, depression, urinary incontinence, bowel incontinence, and chronic low back pain who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 53 hours/week. The patient was hospitalized for advanced Parkinson's with worsened muscle rigidity with acute ambulatory dysfunction. The patient saw his primary care physician (or provider) (PCP) for a follow-up of recent hospitalization noting the patient lived alone, was unable to sit himself up in bed unassisted and even with 2 assistants, and was unable to maneuver using a urinal or stand at the side of the bed upon presentation to the ED. The patient's daughters attended the PCP follow-up visit and noted they were working on approval for 24-hour services because the patient needed an aide overnight as well. The office note also stated the patient was having worsened constipation and worsened chronic pain. The PCP referenced a neurology note stating "hospitalizations are typically precipitated by freezing or falls, the patient will sometimes add that he has some shortness of breath or chest pain. In general, these hospitalizations will terminate when he leaves against medical advice (AMA), and has been offered both assisted living, rehab [rehabilitation], and nursing home placement all of which he has very adamantly refused. He is currently living on his own in a house and is approved for 53 hours of help a week but his daughters have only been able to get 2 days for 13 hours. One of the daughters is coming by 5 evenings a week and her sister has been only able to come recently but was coming 2 or 3 times a week before hurting her neck. They do have security cameras in the house and report that he is struggling 24/7 and really could benefit and use more support than he is getting. He has very frequent freezing and he will not use a pillbox. They're very suspicious that he is inconsistent with the use of his medications and this may be contributing to his condition".
The patient underwent an assessment assessing the patient at total assistance with the tasks of ordinary housework while maximum assistance with the tasks of meal preparation, managing finances, stairs, shopping, bathing, personal hygiene, dressing upper/lower body, and toilet use. With the tasks of managing medication, phone use, transportation, walking, locomotion, transfer toilet, and eating while it was noted activity did not occur for the activity of bed mobility. Notes from the assessment stated the patient lived alone, was attending physical therapy (PT) two times per week, had a decline in activities of daily living (ADL) status over the last 90 days, and had deterioration of overall self-sufficiency in the last 90 days. In addition, the assessment stated the patient's muscles "freeze up" leaving him motionless and this happens several times a day and this happens several times throughout the day and durations of immobility may vary. The assessment also stated the patient was afraid to be alone as he has sat motionless for hours at a time, caregivers stated the member loses control over his bowels and bladder when this occurs and they return the next day to find him sitting in feces, the patient is unable to perform toilet hygiene independently, the patient was able to transfer from sitting to stand using lift recliner, the patient was often unable to feed himself due to weakness, tremors, and poor coordination, the patient sleeps in a lift recliner as he is unable to get himself out of bed, the patient is often up at night due to anxiety stating he was afraid to be alone due to unpredictable episodes of immobility, and the patient required medication reminders as his condition is exacerbated by missing his medication.
The insurer sent an initial adverse determination denial notice denying the request to increase CDPAP services. The patient saw his neurologist for a follow-up visit with the office note stating the patient's daughter helps set up the patient's medications and the daughters were working on getting more hours to help at night as their goal was to keep the patient home as long as possible. Office notes also stated the patient and the daughter noted progression in the patient's motor symptoms with increased gait impairment and freezing. Medications were adjusted at this office visit, a referral to occupational therapy (OT) and physical therapy (PT) was made, and the provider stated it was medically necessary to increase and maximize the in-home services, including overnight.
The patient's neurologist sent a letter voicing concerns that the patient's current home care hours were not sufficient and as the patient's disease advances he will likely need around-the-clock in-home care to assist with all of his ADLs including the overnight periods, for which he has no current in-home services currently. The PCP provided a letter stating he was in her medical opinion requiring increased aid services in the home due to worsening chronic medical conditions. The provider also stated the patient needs additional aide services as a matter of safety and care as he required assistance with all activities of daily living. The patient's daughter filled out an appeal request stating there was a medical necessity for increased use of in-home care due to a decline in the patient's Parkinson's disease.
The insurer sent a final adverse determination denial notice denying the request to increase CDPAP after received the patient's neurologist notes. The insurer made the decision, that the patient lived alone, the patient could make decisions for himself and directed his care, the patient had supportive daughters, because of his freezing episodes related to Parkinson's he should continue to follow-up with his doctor/neurologist as aides do not manage medical conditions or behaviors, the patient ambulated with a cane and an aide could not always be with him in the home, the plan recommended the patient use his mobility device, the patient should work with his doctor to get a referral to physical therapy and occupational therapy, the plan recommended a hospital bed with rails to help him turn while in bed, they recommended a bed cane, bedside commode, and raised toilet seat. In addition, the insurer recommended speaking to a care coordinator to review the patient's current needs and living conditions and to recommend the most suitable and safe setting for the patient. The plan also recommended the approved hours could be arranged to best meet the patient's morning and evening needs.
The patient's PCP provided another letter stating the patient needed continuous supervision and cannot have a caregiver who cannot provide continued supervision to the patient as he is up and down all night with an increased fall risk, increased gait stability and needed someone awake during all hours of the shift to meet his needs. The provider also noted not having 24-hour supervision is a hazard to his health and safety. The provider appealed the denial decision. The patient appealed the denial decision. The patient's neurologist provided a letter stating the patient had moderately advanced Parkinson's disease with associated postural instability, falls, cognitive impairment, anxiety, and depression with the advancement of the disease, particularly from a motor standpoint, where he is having more difficulties with balance, gait, and falls. The provider also noted the patient had been having more freezing episodes and unpredictable off periods, which increased his risk for falls. The neurologist also noted he was adjusting the patient's medication to improve the patient's motor function and quality of life but was extremely concerned that the current level of home care was not sufficient for the patient. Lastly, the provider felt it was medically necessary to request CDPAP services 24 hours/day, split shift, 7 days/week, to total 168 hours/week.
At issue is the medical necessity of CDPAP services 24 hours/day, split shift, 7 days/week, to a total of 168 hours/week.
The services are medically necessary. There is documentation of the patient's worsening cognitive and physical functioning. The patient had unpredictable periods of freezing and off sessions which render the patient unable to care for himself. The patient requires total assistance with all ADLs when he has unpredictable periods of "freezing" due to his Parkinson's disease. The patient has documented urinary incontinence and bowel incontinence. The patient had 24-hour care needs and a task-based assessment tool should not have been utilized by the insurer to calculate CDPAP service hours. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with the safe completion of ADLs/Instrumental activities of daily living (IADLs). The patient's unpredictable nature of freezing and off episodes would not allow a CDPAP service aide to obtain at least 5 hours of uninterrupted sleep. The patient's condition is anticipated to worsen and progress. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, CDPAP services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in his own home.