Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease and dementia
Treatment: Increase in personal care services, 24 hours x 4 days per week, live in, total of 96 hours per week
The insurer denied the increase in personal care services, 24 hours x 4 days per week, live in, total of 96 hours per week.
The denial is overturned. 

This female has conditions including Parkinson's disease, dementia, status post (s/p) hip fracture, coronary artery disease (CAD), and anxiety/depression.  She was discharged from rehab.  She is appealing denial of increase in personal care services, 24 hours times four days per week, live in, total of 96 hours per week.  She has been approved for personal care services (PCS), nine hours times four days per week, total of 36 hours per week and 24 hours per week consumer directed personal assistance services (CDPAS) (eight hours times three days per week.).  The son noted the patient needs assistance with toileting and repositioning at night.  Uniform Assessment System (UAS) evaluation completed shows minimally impaired condition and functional status: total dependence with housework and locomotion; maximal assistance with meal preparation, managing finances, shopping, bathing, lower body dressing, walking, and toileting; and extensive assistance with managing medications, phone use, personal hygiene, upper body dressing, bed mobility, and eating.  The patient is wheelchair dependent.  She is infrequently incontinent of bowel and bladder.  

Appeal letter from the provider notes the patient has been experiencing exacerbation of Parkinson's disease.  She is status post a fall that resulted in a hip fracture.  Notes the patient needs assistance with activities of daily living (ADLs) as already accounted for in the UAS evaluation.  Appeal letter from another provider notes the patient has deteriorated over the past few months.  She has had multiple falls due to antalgic gait.  The appeal states the patient fully needs 24/7 care.  An appeal letter from New York State notes the patient needs assistance with activities of daily living (ADLs) and has unscheduled toileting needs.

Yes, the proposed treatment is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding.  

This patient has several chronic conditions including Parkinson's disease and dementia.  She is status post recent hip fracture after a fall.  She was discharged from rehab.  She is appealing denial of increase in personal care services, 24 hours times four days per week, live in, total of 96 hours per week.  She has been approved for personal care services (PCS), nine hours times four days per week, total of 36 hours per week and 24 hours per week consumer-directed personal assistance services (CDPAS) (eight hours times three days per week.).  The patient is wheelchair bound.  Her son notes she needs assistance with toileting and repositioning at night.  UAS evaluation completed shows the patient needs assistance with all ADLs/instrumental activities of daily living (IADLs).  She is infrequently incontinent of bowel and bladder.  The appeal letter notes the exacerbation of Parkinson's disease and deterioration since hip fracture.  This patient has significant impairments that have progressed per appeal statements.  The patient is wheelchair bound and noted to need assistance with repositioning.  The approved hours are inadequate to meet the patient's needs for assistance with ADLs/IADLs.  The proposed increase in personal care services (PCS) to 24 hours times four days per week, live in, total of 96 hours per week, is medically necessary and appropriate to meets this patient's needs.