Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease 
Treatment: Increase in Personal Care Aide (PCA) Level 2 Services: 14 Hours per Day, 7 Days per Week (Total of 98 Hours per Week)
The insurer denied Increase in Personal Care Aide (PCA) Level 2 Services: 14 Hours per Day, 7 Days per Week (Total of 98 Hours per Week)
The determination is overturned.

The patient has a medical history significant for Parkinson's disease, osteoarthritis and diabetic neuropathy causing significant limitations with mobility and ambulation. Review is for the medical necessity for personal care assistance hours. The patient was initially approved for 7 hours a day, 7 days a week. The request has  been made for 14 hours a day for 7 days a week.
As it relates to her care needs, the patient is totally dependent on assistance with meal preparation. She is totally dependent with regards to housework. She requires significant assistance managing her medications. Also, with her physical limitations, she is unable to perform any shopping such as for food, toiletries or otherwise. The patient requires maximal assistance with bathing including bathing parts of her body as well as transferring to and from the shower or tub. Also, she has extensive assistance needs regarding personal hygiene such as hair care and dental care. She needs extensive assistance for dressing of the upper body and maximal assistance requirements for dressing the lower body. Any walking, locomotion or mobility requires maximal assistance defined is necessitating 2 plus (+) helpers or weightbearing support for more than 50% of the subtasks. This includes transferring to and from the toilet as well as use of the toilet. The patient is noted to have incontinence of urine and is continent of stool. Additionally, she has extensive assistance requirements regarding bed mobility and eating. The patient is noted to also be experiencing pain on a daily basis described as intermittent but moderate in intensity. She does have a supportive family. She has a daughter who assists in her care but is not there the majority of the time. In review of the assessments, her care needs did increase.
At issue is the medical necessity of a Requested Increase in Personal Care Aide (PCA) Level 2 Services to 14 Hours per Day, 7 Days per Week (Total of 98 Hours per Week).
The requested services are medically necessary.
The patient has significant and persistent care needs that are present throughout the day. Her care needs are extensive and she has significant debility requiring a large degree of assistance at all hours of the day. With her limitations in mobility, her toileting needs may be present at all time of the day and a singular 7 hour block of time is insufficient to provide for her needs in this context throughout the day. Although the care plan lists several assistive devices and tools within the home, her physical limitations still require significant personal aide assistance utilizing these. Without this assistance, the patient is at an increased risk for increasing frailty, falls, skin break down and the subsequent morbidity and mortality these can cause.
Therefore the services requested, PCA Level 2, 14 hours per day are medically necessary and appropriate.