Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, supra-nuclear palsy, gait disorder and cognitive impairment. 

Treatment: Personal Care Services of 8 hours per day, 6 days per week for a total of 48 hours per week. 

The insurer denied coverage for Personal Care Services of 8 hours per day, 6 days per week for a total of 48 hours per week.

The denial is overturned. 

This is a female patient with a past medical history of Parkinson's disease, supra-nuclear palsy, gait disorder and cognitive impairment.  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her son were present on the call.  The patient lives with her spouse in a three bedroom apartment with two flights of stairs, but there is no elevator access.  However, a stair lift is installed. The patient's son lives ten minutes away and is able to assist, if needed. 

Needs are: 

- Total dependence for ordinary housework;
-Maximal assistance for meal preparation and shopping;
- Extensive Assistance for managing stairs, transportation, equipment management, bathing and dressing her upper and lower body;
-Limited assistance for managing finances, managing medications, personal hygiene, walking, locomotion, toilet transfer and toilet use;
Supervision/Independence for bed mobility and eating.
- Cognition: There is mild impairment. 
- Continence: She is frequently bladder incontinent and infrequently bowel incontinent. The patient uses pull ups for her incontinence

The patient uses an assistive device for locomotion indoors.  

The patient and her son reported that the patient fell down in the outpatient physical therapy office while doing physical therapy.  The patient denied any minor or major injuries.  The patient's son also reported the patient fell down at home, but he was unable to provide details on what happened and when it occurred.  

An increase to personal care services has been requested 8 hours per day, 6 days per week for a total of 48 hours per week is being requested.

In a letter the patient's Caseworker noted the patient's medical history and healthcare needs.  The patient's functional status is declining.  The letter stated it is impossible for the patient to be alone for a moment, as she can barely move even with an aide.  While the letter also stated the original request for 8 hours per day is not sufficient at this time and the letter requested approval of a minimum of 12 hours per day, 7 days per week the issue under review is driven by the insurer's final adverse determination which denied 8 hours.

The patient needed assistance with transfers, ambulation and toileting when assessed in the UAS.  The patient's Medical Doctor (MD) has noted that the patient's functional capacity has worsened.  She is incontinent and has problems handling her own toileting.  She had been going to Physical Therapy (PT) and Occupational Therapy (OT) but no longer does.  She does not have reliable scheduled informal caregiver hours.  Given the tasks she requires and her increasing limitations, further increase in hours are supported by the record. The number of hours cannot exceed what was denied by the insurer. The health plan did not act reasonably with sound medical judgment.

The insurer's denial of coverage for the requested Personal Care Services of 8 hours per day, 6 days per week for a total of 48 hours per week is overturned. Furthermore, the additional request to increase to 12 hours/day are supported and should be provided. Medical Necessity is substantiated.