Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinsons Disease
Treatment: Personal Care Services (PCS) - 12 Hours a Day, 3 Days a Week: Total of 36 Hours per Week
The insurer denied the Personal Care Services (PCS) - 12 Hours a Day, 3 Days a Week: Total of 36 Hours per Week.
The health plan's determination is overturned. 

The patient is a female with a medical history notable for Parkinson's disease, osteoarthritis, and incontinence. The patient is approved for 29 hours per week of consumer directed personal assistance services (CDPAS) and 20 hours per week of PCS (total of 49 hours per week). The patient and her care team requested an increase to 36 hours per week of personal care services (a total of 84 hours per week of combined services), and the health plan denied the request. This denial is the subject under review.
The patient's neurologist provided a letter of support for this appeal. The letter states that the patient is unable to perform any activities of daily living without assistance. She needs physical assistance with transfers, toileting, bed repositioning, and ambulating. Her needs are unpredictable and unscheduled. She has had significant weight loss and cannot physically lift a fork at this time. She is frequently dehydrated. The physician recommends around-the-clock care for the patient.
A patient advocate wrote a letter on behalf of the patient. The letter notes that the patient is 87 pounds and suffers from malnourishment and frequent dehydration. Her son is her main caregiver and cares for her as much as he can, but he "cannot sustain this constant level of care without detriment to her own health and quality of life." The letter notes that the patient is frequently incontinent and needs multiple bedding and clothing changes throughout the day and night. She needs assistance with all activities of daily living and transfers. Her needs are unpredictable and unscheduled.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives in her apartment with her husband. The patient was alert and oriented with periods of forgetfulness. She is able to direct her own care. For her instrumental activities of daily living (IADL's), she requires maximal assistance for meal preparation, housework, phone use, stairs, shopping, and transportation. For her activities of daily living (ADL's), she requires maximal assistance with bathing, dressing, hygiene, walking, locomotion, toilet transfers, and toilet use. She requires extensive assistance for bed mobility and eating. She is frequently incontinent of urine and uses diapers for incontinence care.
 
The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service of PCS - 12 Hours a Day, 3 Days a Week: Total of 36 Hours per Week is medically necessary for this patient. The patient has severe functional limitations that cause her to require hands on assistance for all ADL's and IADL's. She also has frequent urinary incontinence. Her care needs are expected to be continuous and unscheduled in nature. Her son has been providing her main level of support, but the documentation states that he has been working at a level that is not sustainable. The additional personal care services hours are medically necessary and reasonable for the patient to sustain her health in the home.

The health plan's determination of medical necessity is overturned in whole.