Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease (PD). 
Treatment: Personal care assistance (PCA) services 24 hours live in x 7 days (91 hours per week). 

The insurer denied coverage for personal care assistance (PCA) services 24 hours live in x 7 days (91 hours per week).  The denial is overturned. 

According to the medical records, the patient is a female with a history of Parkinson's Disease (PD) and coronary heart disease. Per the Uniform Assessment for New York (UAS-NY) the patient lives alone in a one-bedroom apartment. She was hospitalized after sustaining a fall off her bed resulting in punctured lungs and three broken ribs. She was then transferred to a nursing home (NH) for rehabilitation. She was then transferred home. She is alert and oriented (A+O) x 3. The patient can activate the personal emergency response system (PERS) or call 911 in an emergency. The patient requires maximal assistance with meal preparation. The patient requires total dependence for housework. She requires extensive assistance with managing medications, personal hygiene, dressing, locomotion, and toilet transfer. She is frequently incontinent of urine. The patient is requesting personal care assistance (PCA) services 24 hours live in x 7 days (91 hours per week). 

"Activities of daily living (ADLs) is an important measure of the quality of care provided in home healthcare (HHC), but few studies describe the ADLs of HHC patients. The objectives of this study were to (1) describe the types and levels of ADL dependency among patients receiving home care, (2) identify the risk factors for severe ADL dependency at admission, and (3) identify the predictors of ADL improvement during a HHC stay. This was a secondary data analysis of a 5% random sample of the national Outcome and Assessment Information Set (OASIS-C) for the year 2013. The dependent variables were severe ADL dependency level at admission and ADL improvement from admission to discharge. About two-thirds (65%) of the patients had severe ADL dependency (dependence in 7 or more ADLs) at admission. Older age, female gender, and impaired decision-making were associated with severe ADL dependency on admission. Of the 105,654 patients, 58.1% experienced ADL improvement. ADL improvement was associated with increasing home health care length of stay, being female, and prior inpatient stay. Clinicians, policy makers and agencies could focus on modifiable characteristics to achieve the goal of ADL improvement. (Osakwe, Z. T. et al. 2019). 
                                                       
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The attending physician's recommendation is that the patient needs 24-hour care from PCA as she needs help with moving or transferring from one place to another place within the apartment. She cannot transfer from sofa to bed or vice versa without help. She can't go to the toilet without help, as she is at high risk for falls. She recently had serious fall and can have another one without 24-hour PCA. 

The personal care assistance (PCA) services 24 hours live in x 7 days (91 hours per week) are considered medically necessary for this patient. She has severe PD and is unable to do anything without help. She has incontinence and needs help to go to the toilet, needs help with toileting, change diapers, and come back to bed. She also needs help to move from one place to another place within the apartment like sofa to bed to floor, et cetera. Without 24 hours of PCA, she is very risky to fall. She already had a very serious fall recently, which could have been prevented had she had 24 hours of PCA. 

The insurer's denial of coverage for personal care assistance (PCA) services 24-hour live-in x 7 days (91 hours per week) is overturned. Medical Necessity is substantiated.