Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease (PD) and Polyosteoarthritis
Treatment: Personal Care Aide (PCA) Level 2: 8 hours/day, 7 days/week, for a total of 56 hours/week
The insurer denied coverage for PCA level 2: 8 hours/day, 7 days/ week, for a total of 56 hours/week.
The denial is overturned.

This male has experienced functional decline associated with chronic medical conditions and needs assistance with most daily activities. The patient lives alone. He has been receiving personal care aide (PCA) services 6 hours/day, 7 days/week (42 hours/week) to assist with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). He also receives some informal help from family. The patient's physician (as patient designee) requested increase of PCA services to 8 hours/day, 7 days/week (56 hours/week), which was denied. 

The most recent Uniform Assessment System (UAS) provided for review was done.  Functional status for IADLs indicates patient is totally dependent for ordinary housework; he needs maximal assistance for meal preparation, shopping, managing medications; extensive assistance for transportation, stairs; limited assistance for managing finances; setup help for phone use. For ADLs the patient needs extensive assistance for bathing, dressing lower body, walking, locomotion, transfer toilet; limited assistance for personal hygiene, dressing upper body, toilet use, bed mobility; setup help for eating.

The patient has had increasingly bad falls due to gait difficulty (noted to be partly due to knee pain in addition to effects of Parkinson's Disease). He walks with rollator at home; uses wheelchair outside. Recently, he has been more bradykinetic, with severe body tremors and stiffness. He has trouble sleeping at night. The patient needs support to go outside for light exercise to help relieve rigidity and stiffness. Medications include carbidopa-levodopa 25/250mg (milligrams) 4 times per day and entacapone 200mg 3 times per day. Entacapone is used to prolong the effect of each dose of carbidopa-levodopa (decrease "off" periods). 

Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. These care needs must be considered in the determination of the patient's personal care service hours. Considering the information provided for review (UAS and neurologist's letter/office note), it is medically necessary for the patient to have caregiver assistance to properly and safely complete all daily activities throughout the day. Assistance is necessary to help prevent falls/injury, ensure adequate nutrition and hydration and timely administration of medications, and help prevent toileting related adverse events (falls, skin damage). ADLs such as transfers, walking, toileting/incontinence care are not scheduled tasks and occur at various times throughout the day. In addition, the level of assistance needed may increase at times during the day due to fluctuations of symptoms from PD and arthritis. 

The patient is currently receiving PCA services 42 hours/week. This is not sufficient to address all the patient's ADLs and IADLs care needs each day, as described above. 

Recommendation is given for approval of PCA services level 2: 8 hours/day, 7 days/week, total of 56 hours/week.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for PCA level 2: 8 hours/day, 7 days/week, for a total of 56 hours/week is substantiated.