Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease. 
Treatment: Home Health Care/Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week. 

The health plan denied the requested health service/treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week as not medically necessary. 

The health plan's determination is overturned. 

This is a case review for a male with a medical history notable for Parkinson's disease, dementia, and left sided hemiplegia. He was receiving 42 hours per week of consumer directed personal care services. The patient's care team requested an increase in personal care services to 84 hours per week. The health plan did increase to 52 hours per week. 

A letter of support for this appeal was provided by the patient's daughter. The letter states that his level of functioning has declined greatly since a hospitalization for COVID. He needs assistance with nearly all activities of daily living. The letter states he wakes up hourly throughout the night due to "hallucinations and urge to urinate (due to Parkinson's)." Due to urinary incontinence, he wears diapers which needs to be changed. He requires medications to be administered every few hours to help with his movements and also to regulate his blood pressure, which can vary to the extremes due to his Parkinson's disease. 

A letter of medical necessity was provided by the patient's physician. The letter states that the patient has had deterioration over the past 3-4 months with worsening dementia and fatigue, and that he requires assistance with all activities of daily living (ADLs). The physician feels that 6 hours per day is no longer sufficient to meet his personal care needs. 

A Uniform Assessment System (UAS) was completed and was available for review. From a functional standpoint, the patient requires total dependence for meal preparation, housework, and finances. He requires extensive assistance for managing medications. For his ADL's, he requires maximal assistance for dressing upper/lower body, walking, locomotion, toilet transfer, and toilet use. He requires extensive assistance for bathing, hygiene, bed mobility, and eating. He is incontinent of stool and urine with no control present and uses diapers. Compared with a prior assessment, the patient showed a decline in functioning level in several ADL's. A tasking tool associated with the most recent UAS recommended 52.25 hours per week for personal care assistance.
At issue is the medical necessity for the requested health service/treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week. 

The requested health service/treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week is medically necessary for this patient. 

This patient has Parkinson's disease with mobility issues, dementia, and incontinence of urine and stool. The most recent UAS demonstrates significant need for personal care and assistance with ADL's and instrumental activities of daily living (IADLs). In addition, the treating physician states that he has clinically deteriorated over the past several months, so he likely is requiring more than indicated in this assessment. Tasking tools can also underestimate the true need in a patient who requires around the clock care for incontinence. Per the testimony, his dementia is worsening. The combination of incontinence and dementia can be very difficult to manage on limited personal care hours because the patient's needs are unpredictable and sporadic throughout the day and night. He will need frequent continence care to prevent skin breakdown and infection; therefore, the hours spent by the personal care aide would be medically necessary and not strictly for safety monitoring and supervision.