Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's disease, type 2 diabetes mellitus, dementia, hypertension and insomnia.
Treatment:  Personal care assistance, level II, 24 hours per day, 7 days per week, split shift.

The insurer denied coverage for personal care assistance, level II, 24 hours per day, 7 days per week, split shift.  The denial is overturned.

This elderly patient has significant functional impairment associated with several medical conditions and requires assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The Uniform Assessment System (UAS) reports the patient lives alone, but the patient advocate's letter indicates the patient lives with her developmentally disabled son. The patient has another son who is identified in the UAS as the only informal helper. The patient has been receiving personal care assistance (PCA) services 9 hours per day, 7 days per week, total of 63 hours per week. The patient (via designee) requested increase of PCA services to 24 hours per day, 7 days per week, split shifts, which was denied. 

The functional status report for IADLs indicates patient was totally dependent for ordinary housework, managing finances, shopping, transportation; she needed maximal assistance for meal preparation, managing medications, phone use, stairs, equipment management. For ADLs, the patient was totally dependent for bathing, personal hygiene, dressing upper/lower body, toilet use, bed mobility; she needed maximal assistance for walking, locomotion, eating. Transfer toilet: activity did not occur during entire period.

The patient has Parkinson's disease (PD), a progressive neurodegenerative disorder. Motor symptoms include tremor, bradykinesia, rigidity, postural instability, unsteady gait; all of which can adversely affect ability to perform daily activities.  Non-motor symptoms include autonomic dysfunction (e.g., blood pressure changes including orthostatic hypotension, bowel and bladder dysfunction); cognitive impairment (e.g., memory impairment, dementia); mood disorders (anxiety, depression). Other symptoms associated with PD include dizziness, fatigue, pain, sleep disturbances. 

Parkinson's disease affects mobility. The UAS indicates patient needs maximal assistance for walking, which is probably at least partly due to PD. The physician's office note reports difficulty walking and the physician's letter reports patient is in a wheelchair (unclear if this is now the routine method of locomotion at home). The UAS indicates the patient has difficulty standing up from a sitting position (transfer activity), which often occurs with PD. 

PCA tasks include housekeeping; meal preparation; assist with medications; routine ADLs (bathing, dressing, personal hygiene, eating); plus unscheduled and/or recurring ADLs, e.g., toileting/incontinence care; repositioning; out-of-bed mobility (if the latter still occurs). It is medically necessary to have a caregiver present and awake to provide care when needed through the day and night to help prevent incontinence associated skin damage; decrease risk of urinary tract infection (UTI); help prevent pressure ulcers; improve patient comfort, ensure adequate food/fluid intake. Considering the high level of assistance the patient needs for all ADLs, and the probable frequency needed to properly manage her ADL care needs at night (e.g., incontinence care, repositioning), it appears the patient's care needs are not compatible with PCA live-in services (which includes 5 hours of uninterrupted sleep per day for the aide); and so continuous (split shift) services are necessary.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care assistance, level II, 24 hours per day, 7 days per week, split shift is substantiated.