Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Increase in personal care services from 49 hours per week to 24 hours per day (Split-Shift).
The insurer denied an increase in personal care services from 49 hours per week to 24 hours per day (Split-Shift).
The health plan's determination is overturned.

The patient is a female with a medical history notable for Parkinson's disease, hemangioma of the spine with myelopathy, and bed-ridden status. The patient is approved for 49 hours per week of personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift).
The patient's neurosurgeon provided a letter of support. The letter states that the patient underwent a cervical vertebrae (C)7-thoracic vertebrae (T)1 laminectomy for resection of a tumor. Her postoperative course has been complicated by pressure ulcers. The physician requests additional care including a specialized mattress to promote healing and prevent further skin breakdown.
The patient's pulmonologist provided a letter of support for this appeal. The patient has bronchiectasis with frequent respiratory infections and asthma. The physician requests an increase in home health aide hours.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives with her son in an apartment. Her son has been providing informal support but he just got married and will be moving out of the house; he also works full time. The patient was alert and oriented with periods of forgetfulness. She is able to direct her own care and her cognition was minimally impaired. For her Instrumental activities of daily living (IADL), she requires total dependence for housework, stairs, and transportation. She requires maximal assistance for meal preparation and shopping. She requires extensive assistance for finances and medications. For her activities of daily living (ADL), she requires total dependence for bathing, dressing lower body, locomotion, and toilet use. She requires maximal assistance for hygiene, dressing upper body, and bed mobility. She is frequently incontinent of urine and stool. A task tool associated with the UAS recommended 42.58 hours per week to address her personal care needs. 

The requested health service of an increase in personal care services from 49 hours per week to 24 hours per day (Split-Shift) is medically necessary for this patient. The patient is bedbound and is totally reliant on others for all personal care needs. She will soon be living alone. The patient's physician provided a letter of support. The letter states that the requested increase in personal care hours is medically necessary for the patient. The patient has been non-ambulatory since her spine surgery and her condition is worse than it was (when she was granted 84 hours of weekly personal care assistant (PCA) care). She has a stage 3 sacral pressure ulcer and spends 21-22 hours per day in bed. She needs turning and repositioning every 1.5-2 hours to promote healing. She is incontinent of urine and stool; she is totally dependent on others for changing incontinence products which must be done promptly when needed. An updated letter states that the patient has been receiving private pay 24 hour care which will be discontinued due to financial reasons.
Her care needs are expected to be continuous and unscheduled throughout the day and night. Therefore, split-shift 24 hour personal care is medically necessary for the patient. Failure to address her personal care needs could result in worsening of her pressure ulcer and/or infection.  
 
The health plan's determination of medical necessity is overturned in whole.