Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease, Dementia.

Treatment: Personal Care Aide (PCA)-Level 2, 63 hours/week; 9 Hrs x 7 days.

The insurer is denied coverage for Personal Care Aide (PCA)-Level 2, 63 hours/week; 9 Hrs x 7 days.

The denial is overturned. 
This is a female patient with a complex medical history that include coronary heart disease, hypertensive heart disease, diastolic heart failure, COPD, shortness of breath, nonalcoholic steatohepatitis (NASH), cirrhosis of liver, Parkinson's disease, insomnia, urge incontinence, GERD,  fecal urgency, constipation, dry eye syndrome, fracture of scapula, gait abnormality, repeated falls, pain causing significant functional impairment.  The patient (via designee) requested increase of personal care aide (PCA) services from 49 to 63 hours per week (around the time the patient was being discharged from a rehab facility).  The patient was briefly in the hospital and transferred to rehab/nursing home where she currently resides.  

Elderly people often experience functional decline due to cumulative and interactive effects of multiple co-morbidities and medications. The patient has several chronic medical conditions that most likely have a substantial impact on her ability to perform daily activities: 
- Parkinson's disease (PD): The motor symptoms of PD include tremor, rigidity, bradykinesia, gait abnormality. These symptoms can respond well to levodopa and improve physical function. However, people who take levodopa often experience "off" periods when the medication dose wears off. During this time, the patient's functional ability can significantly decline until the next dose of levodopa takes effect. Non-motor symptoms of PD include dizziness, sleep disorders, fatigue, pain, among others. These symptoms do not usually respond to levodopa and may have variable response to other treatments. 
- COPD: The severity of the patient's lung disease is not clearly described in the available records.  She had an episode of wheezing one evening recently in the nursing home and was treated with nebulizers and steroids. Elderly people with COPD often experience dyspnea, fatigue and decreased endurance for daily activities. During acute exacerbations, the patient's functional ability can decline further. The UAS indicates the patient needs assistance with medications. 
- Heart failure: The UAS indicates patient has diastolic heart failure.  Elderly people with heart failure often have functional decline with daily activities as the disease progresses, with symptoms including: fatigue and dyspnea. The patient takes diuretics, but it was noted she is not always compliant with spironolactone due to side effects. The hospital discharge summary indicated patient had edema (2+) of lower extremities.
- Cirrhosis/NASH: The patient has ascites and recently had paracentesis; discharge summary noted patient felt better. After the procedure the patient still had moderate ascites on ultrasound. Advanced liver disease and ascites can cause fatigue and dyspnea. 
The maximum number of PCA hours that can be recommended for approval from this review is limited by the request, i.e. PCA 63 hours per week. If the nursing home physician determines the patient to be medically stable for discharge, then the physician and nursing home staff will need to develop a plan for safe discharge, which includes the patient's personal care needs. 

Personal Care Aide - Level 2, 63 hours/week; 9 hours x 7 days are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Aide (PCA)-Level 2, 63
hours/week; 9 Hrs x 7 days is substantiated. The insurer's denial is overturned.