Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care.
The health plan denied the requested increase in personal care worker (PCW) service hours. 
The health plan's determination is overturned.

The patient is a female with a past medical history of Parkinson's disease, low blood pressure and high blood pressure. Currently the patient is approved hours at 30 hours per week.
The patient had been assigned personal care assistance (PCA) services based on an assessment tool performed assessing the patient with modified independent, and cognition with no memory problems, she has no hearing or vision difficulties. The patient requires total dependence with the task of ordinary housework and meal preparation. The patient was assessed at extensive assistance with the task of bathing, personal hygiene, dressing upper body, dressing lower body, limited assistance with walking and locomotion, transfer to the toilet, toilet use, limited assistance with bed mobility and extensive assistance with eating. She was noted with no change in activities of daily living (ADL) status in the last 90 days, and with no change in self-sufficiency.
The patient underwent a reassessment assessing the patient as modified independent, cognition with no memory problems. She has no hearing or vision difficulties. She requires total dependence with task of ordinary housework and meal preparation. The patient was assessed at extensive assistance with task of bathing, personal hygiene, dressing upper body, dressing lower body, walking, locomotion, transfer to the toilet, toilet use, limited assistance with bed mobility and excessive assistance with eating. She was noted with a decline in ADL status in the last 90 days, with deterioration in self-sufficiency. She is frequently bladder incontinent and bowel continent.
The patient's primary care provider wrote a letter of medical necessity indicating that the patient suffers from end stage Parkinson's Disease leading to autonomic dysfunction. It was noted that she requires assistance with all her ADLs and instrumental activities of daily living (IADLs). Her primary care physician also stated that she had trouble with ambulation with poor balance, placing her at risk for falls.
At issue is the medical necessity of Increase in Personal Care Worker (PCW) services; 5 days per week, 8 hours per day (Monday-Friday), 40 hours per week.

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

The requested health service/treatment of Increase in Personal Care Worker (PCW) services; 5 days per week, 8 hours per day (Monday-Friday), 40 hours per week is medically necessary for this patient.
The assessment tool performed indicated the patient required assistance with several tasks, including, housework, meal preparation, bathing, dressing upper/lower body, toileting, personal hygiene, and locomotion. She has also been noted to have a decline in ADL status and deterioration in self-sufficiency. She also does not any informal helpers for some hours during the day and requires 1 person assist with mobility and toileting. The requested increase in assistance was not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Per the primary care physician (or provider) (PCP) letter, the patient has a diagnosis of Parkinson's disease with freezing episodes, impaired gait with difficulty with ambulation which leads to an increased risk of falls. Per PCP she had a recent fall which resulted in her hitting her head. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 40 hours are medically necessary.
Therefore, the requested health service/treatment of Increase in Personal Care Worker (PCW) services; 5 days per week, 8 hours per day (Monday-Friday), 40 hours per week is medically necessary.