Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease and paranoid schizophrenia.
Treatment: Increase in personal care aide (PCA) level II: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week, for a total of 168 hours per week (split shift).
The insurer denied the increase in personal care aide (PCA) level II: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week, for a total of 168 hours per week (split shift).
The denial is overturned. 

This male has conditions including Parkinson's disease and paranoid schizophrenia.  He is appealing denial of personal care aide (PCA) 24 hours, split shift.  He was approved for personal care aide (PCA) 72 hours per week.  Uniform Assessment System (UAS) evaluation performed shows minimally impaired cognition and functional status: total dependence with housework, stairs, shopping, and transportation; maximal assistance with meal preparation, managing medications and finances, bathing, lower body dressing, walking, locomotion, and toileting; extensive assistance with personal hygiene, upper body dressing and bed mobility; limited assistance with phone use; and supervision with eating.  He is noted to have increased weakness in last 90 days.  The patient uses a wheelchair when outdoors.  He is occasionally incontinent of urine.  He requires significant assistance to support upper extremities with transfers.  The patient reports needing assistance when repositioning in bed due to weakness and stiffness.  He is status post a fall while in the bathroom.  Compared to Uniform Assessment System (UAS) evaluation performed approximately a year prior, there is a decline in ability to perform stairs, transportation, lower body dressing, walking, locomotion, and toilet transfer.

Appeal letter from the provider indicates the patient's Parkinson's is severe and he needs constant supervision.  It states the patient is a high fall risk.

Yes, the proposed treatment is medically necessary.

The proposed treatment is medically necessary because it is consistent with standard of care.

Personal care services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the provider five hours daily of uninterrupted sleep during the aide's shift.  

This patient has multiple medical conditions, including Parkinson's disease with stiffness and limited mobility.  He is appealing denial of personal care aide (PCA) 24 hours per day, split shift.  He has been approved for 72 hours per day.  Uniform Assessment System (UAS) evaluation completed shows the patient needs assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs) with the exception of eating.  Compared to Uniform Assessment System (UAS) evaluation performed approximately a year prior, there is a decline in ability to perform stairs, transportation, lower body dressing, walking, locomotion, and toilet transfer.  Due to weakness and stiffness, the patient requires significant assistance with transfers, weight bearing and repositioning in the bed.  This patient has significant impairments and limited mobility that requires continuous care.  The approved personal care aide (PCA) 72 hours per week is insufficient to meets this patient's needs with assistance with activities of daily living (ADLs) and personal care as noted above.  The proposed increase in personal care aide (PCA) 24-hour, split shift is medically necessary.