Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Parkinson's Disease
Treatment: Home Health Care/Personal Care Aide services. Personal Care Aide (PCA) Level 2: 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift) - for a total of 168 hours per week.
The health plan denied the requested increase in personal care aide services Level 2: 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift) - for a total of 168 hours per week. 
The health plan's determination is overturned.

The patient is a female with a past medical history of Parkinson's disease, urinary incontinence, bowel incontinence, hyperlipidemia, asthma, hypertension, anxiety, depression, and sciatica who had been assigned personal care aide (PCA) services 4-1/2 hours/day, 5 days/week, to total 22.5 hours/week based on video assessment performed assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing medication, and shopping, while extensive assistance with task of managing finances, and bed mobility. With tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet and toilet use the patient was assessed at limited assistance while independent with tasks of phone use and eating. Notes from the later assessment stated the patient's husband had recently passed. The patient had a fall with an emergency room visit. The patient had another fall. The patient had a follow-up visit with her primary care physician (or provider) (PCP) with office notes stating the patient was having new hallucinations related to Parkinson's and was started on new medication, was being treated for anxiety, was felt to be a good candidate for deep brain stimulation surgery, and the patient's son would be moving back to the area. 
The patient underwent deep brain stimulation surgery. Overnight care logs noted assistance needs in the overnight hour at least every 3 to 3-1/2 hours. 

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

Yes. There is documentation of worsening functional and cognitive status by the patient's PCP, neurosurgeon, and neuropsychologist. The patient's recent assessment tool also noted increased assistance needs with tasks of phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. The patient previously had informal help from her husband who passed away. The patient's son was also providing informal help, but he was moving back home to another state. The patient has unpredictable and unscheduled care needs that span a continuum of time. The patient would need PCA services outside of the time that she has informal help and with her son moving back to another state and she would no longer have informal help. Overnight care logs provided indicated the patient had assistance needs with activities of daily living (ADLs) in the overnight hours such that a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). 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, PCA services  Level 2: 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift) - for a total of 168 hours per week are medically necessary for this patient. 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.