Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease and dementia. 
Treatment: Personal Care Services, Level 2; 24 hours per day, 7 days per week (live-in).
 
The insurer denied Personal Care Services, Level 2; 24 hours per day, 7 days per week (live-in).
The denial is overturned. 

The patient is a female with a medical history notable for advanced Parkinson's disease complicated by dementia with behavioral disturbance, hypertension, diabetes, and squamous cell carcinoma who is being evaluated for an increase for Home Care Services. Supporting documentation for this request is provided by the patient's primary care physician and neurologist. Her neurologist has been treating her Parkinson's Disease, and notes that she has progressed with all of the typical motor complications. The treating neurologist also makes note of neuropsychiatric complications including extreme agitation, day-night reversal, and paranoia. There are reports of missed medication doses due to these complications, which have further exacerbated her symptoms. Her primary care physician notes difficulty with going to the bathroom at night when she does not have personal care assistance as well.

Neurology office visit notes indicate rapid progression of symptoms.

A Uniform Assessment System (UAS) Comprehensive Community Health Assessment was performed. Assessment of cognition revealed that the patient had a mild dementia but had procedural skills intact. She was alert and oriented to person and place but not time, and confused day and nighttime. No recent behavioral disturbance was noted in the report. The patient required limited to extensive assistance for activities of daily living (ADL)'s and Instrumental activities of daily living (IADL)'s throughout the assessment. She is noted to meet Nursing Facility level of care due to her diagnosis of dementia and need for assistance with multiple activities of daily living.

At issue is the medical necessity of Personal Care Services, Level 2; 24 hours per day, 7 days per week (live-in).

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

The requested health service/treatment of Personal Care Services, Level 2; 24 hours per day, 7 days per week (live-in) is medically necessary for this patient.
Over the past several months, the patient has had significant medical and functional decline as noted by both her primary care physician and neurologist. This has manifested in decline across the board under the Uniform Assessment System (UAS) for abilities to perform ADL's and IADL's. She is not able to manage her own medications any more due to her advancing dementia. She is also not able to transfer from seated to standing without assistance, which will make all of her ADL's and IADL's challenging. Compounding this problem is worsening dizziness and unsteadiness on her feet, as well as need for maximal assistance to move from seated to standing position.
Comparison of the most recent UAS-New York (NY) assessment to previous assessment is notable for several differences. She exhibited a decrease in mental status, losing orientation to time and thus demonstrating evidence of advancing dementia. All of her functional status evaluation domains showed a decline in the interval, with the patient now requiring total dependence with housework and extensive assistance for medication management. She had incontinence, which was not evident in prior evaluation. Frequency of dizziness episodes with ambulation had increased to daily.
Given the most recent assessment, the patient is very unlikely to be able to continue to care for her own toileting needs during the 14 hours per day that she is alone. The use of incontinence products alone cannot account for these challenges with toileting.
Therefore, the requested health service/treatment of Personal Care Services, Level 2; 24 hours per day, 7 days per week (live-in) is medically necessary for this patient.