Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease (PD); dementia.
Treatment: Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, 84 Hour(s) per Week (12 hours a day, 7 days a week).
The insurer denied coverage for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, 84 Hour(s) per Week (12 hours a day, 7 days a week),. 
The denial is overturned.

This patient is a female with diagnoses that included: Parkinson's disease, REM sleep disorder, dementia, lumbar radiculopathy, major depressive disorder. The patient has pronounced difficulty walking, weakness, stiffness in legs, slowness of movement, difficulty getting up, shuffling gait due to Parkinson's disease and extensive degenerative changes in spine. She has h/o falls. She takes Rytary and Nourianz which gives only partial and temporary control of symptoms. Family reports worsening memory, confusion, and disorientation. She takes Exelon patch. She also has severe depression, anxiety, difficulty sleeping, unable to relax; symptoms only partly controlled with Clonazepam and mirtazapine. She has episodes of poor appetite. Patient requires continuous assistance with activities of daily living (ADL). It is recommended she has home attendant 24 hours a day, split shifts.

The patient had multiple medical problems and functional decline lives alone since her husband died. The patient was receiving PCS 28 hours per week. The patient's daughter reported that her mother's condition has declined since the last assessment, which was around the time of the husband's death. The patient (via designee) requested increase of PCS to 84 hours per week. In response, the insurer approved PCS 42 hours per week. Appeal was requested and denied. The patient's daughter requested an external appeal. 

The UAS indicates patient needed maximal assistance for housework and extensive assistance with most other IADLs except finances (limited assistance). For ADLs, the patient needed extensive assistance for lower body dressing, and limited assistance for all other ADLs, except eating and bed mobility (independent). One of the 2 recent falls reported in the UAS occurred at 5 am when the patient was getting up from bed. Family had to come to help her up from the floor. It appears the patient is at higher risk of harm when she is alone and has no assistance for mobility related activities, with some additional concerns at night.

Based on the available information, it appears the patient needs assistance with ADLs during the night if she is getting out of bed and using the toilet. However, the number of hours that can be approved from this review is limited by the amount requested, as indicated in the insurer's final adverse determination notice which indicated request was for PCS 84 hours per week. The letters from the daughter and physicians indicated request for 24 hour services. It is not known whether the daughter has submitted a separate request for 24 hour split shift services. Considering the patient's condition appears to have declined since the last UAS, re-assessment will need to determine the patient's functional status including nighttime care needs.

Based on the above, the medical necessity for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, 84 Hour(s) per Week (12 hours a day, 7 days a week) is substantiated.  The insurer's denial is overturned.