Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's disease.
Treatment:  Personal Care Assistance services, Level ll, 24 hours per day, 7 days per week (Monday through Sunday, split-shift).

The insurer denied coverage for Personal Care Assistance services, Level ll, 24 hours per day, 7 days per week (Monday through Sunday, split-shift).  The denial is overturned. 

This is a male patient with a medical history of diabetes mellitus, benign neoplasm of prostate, blindness of the right eye, constipation, difficulty walking, dizziness and giddiness, epilepsy, not intractable, with status epilepticus, hypertension, chronic pain, sleep disorder, wandering and Parkinson's disease.  The patient has various chronic medical conditions, extensive functional impairment, recently complicated by several acute medical and traumatic events.  The patient lives alone and has been receiving Personal Care Aide (PCA) services 12 hours per day, 7 days per week.  A request was made for an increase of PCA services to 24 hours per day, split shift, which was denied. 

Uniform Assessment System (UAS) documentation indicates that the patient is totally dependent or needs maximal assistance for all instrumental activities of daily living (IADLs).  For activities of daily living (ADLs), he needs maximal assistance for most ADLs (including walking/locomotion and toileting), except he is totally dependent for lower body dressing, and he needs extensive assistance with bed mobility and eating.  As per UAS documentation, the patient has significant cognitive impairment.  His decision-making capacity for daily tasks is consistently poor or unsafe, and he has short term and procedural memory impairment.  His communication skills are limited to concrete requests and simple, direct communication.  These impairments could have an adverse effect on his ability to perform daily activities and increase risk of falls and accidents during mobility and daily tasks due to unsafe decisions and poor safety awareness.

The patient has several chronic medical conditions that most likely have contributed to his functional decline.  Parkinson's disease affects motor function causing tremors, bradykinesia, rigidity, abnormal gait, and postural instability.  The UAS indicates that the patient has no vision in the right eye and low vision in the left eye.  It is medically necessary for the patient to have a caregiver present 24 hours per day to provide assistance with daily activities throughout the day and night.  The patient needs weight-bearing assistance for transfers, walking, toileting/incontinence care and bed mobility to help prevent falls and related injuries and skin injury.

Assistance from informal caregivers is voluntary, as per New York State (NYS) regulations for personal care services.  When informal caregivers cannot provide the  assistance needed on a consistent basis, then personal care services are indicated to provide assistance with daily activities including ADLs that need assistance at various times throughout the day and night.  The family requested PCA 24 hour split shift services.  The patient has had recent serious injuries most likely resulting from falls.  The patient remains at high risk for falls due to his impaired functional status and medical conditions.  At this time it does not appear prudent to have the patient unattended for extended periods of time.  The patient has recently experienced serious adverse effects of falls; so, it is necessary to consider these events as an alert, and implement proper precautions to try to minimize the chance of future harm. 
	
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for PCA services, Level ll, 24 hours per day 7 days per week (Monday through Sunday, split-shift) is substantiated.  The insurer's denial is overturned.