Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift)
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift)
The denial is overturned.

The patient is an elderly female with a history of general debility due to Parkinson's disease. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased to 168 hours per week (24 hours per day, split of 12 hours times 2, 7 days per week) as against the previously approved 59.5 hours per week (8.5 hours per day, 7 days per week) based on Uniform Assessment System of last year. The patient lives in an apartment alone. The health plan denied the request as not medically necessary because there have not been changes to the patient's activities of daily living for upper body dressing, personal hygiene, bed mobility, walking, locomotion, bathing, toilet transfer, meal preparation, medication management, and housework, but with decline only for lower body dressing, toilet use, and eating, etc. The time previously allotted is stated to be adequate. The additional hours requested are because of the patient's chronic medical conditions, she needs someone to be with her at night, is unable to eat on her own as she chokes, has frequent falls, has diabetes and bed sores, and has other personal care needs, etc. A review of the records shows that the patient has multiple chronic medical conditions such as Parkinson's disease, diabetes mellitus, hypertension, hypothyroidism, multiple decubitus ulcers, dysphagia, incontinence of bowel/bladder, high fall risks, etc. Uniform Assessment System-New York evaluation of 3 months ago shows that the patient requires extensive assistance with phone use; maximum assistance for meal preparation, managing medications, bathing, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, bed mobility, eating; and is totally dependent on housework, managing finances, shopping, lower body dressing, toilet use, etc. Her family support is very limited as she lives alone.

The requested health service is medically necessary.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from the approved 59.5 hours per week (8.5 hours per day, 7 days per week) from Uniform Assessment System of last year to the requested 168 hours per week (24 hours per day split of 12 hours times 2, 7 days per week) is medically necessary based on Uniform Assessment System of 3 months ago in which the patient requires extensive assistance with phone use; maximum assistance for meal preparation, managing medications, bathing, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, bed mobility, eating; and is totally dependent for housework, managing finances, shopping, lower body dressing, toilet use, etc. The patient's family support is very limited as she lives alone.
The reason for denial by the health plan, as stated in the clinical information above, does not align with the patient's disability features as stated in the Uniform Assessment System of 3 months ago as stated above. Therefore, the 168 hours per week (24 hours per day split of 12 hours times 2, 7 days per week) based on Uniform Assessment System of 3 months ago should be approved because the patient requires extensive assistance with phone use; maximum assistance for meal preparation, managing medications, bathing, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, bed mobility, eating; and is totally dependent for housework, managing finances, shopping, lower body dressing, toilet use, etc. Therefore, the requested health service is medically necessary.