Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease

Treatment: Personal Care Services (PCS) 7 hours a day x 7 days a week 

The insurer denied the Personal Care Services (PCS) 7 hours a day x 7 days a week

The denial was overturned.

This is an elderly female who lives alone and needs assistance with instrumental activities of daily living (IADL) and activities of daily living (ADL). She was approved for personal care services (PCS) 28 hours per week (4 hours x 7 days).  She requested increase of PCS to 7 hours per day, 7 days per week (49 hours per week). The patient has a history of Parkinson's, osteoarthritis, torn rotator cuff, and dizziness. It was reported that patient had a tremor and she had trouble with fine motor tasks (e.g. buttons, hair care) but was able to prepare food. The patient was able to walk but wobbles and had difficulty walking in a straight line. Her mental status was mostly intact with occasional word finding difficulty. She needs extensive assistance with transfers on/off the toilet and limited assistance with toilet use. The patient has difficulty with all transfers as it was noted that she has difficulty moving to a standing position unassisted. This is a significant change, as transfer activity is necessary to initiate all mobility around her home (i.e. stand up from a chair or bed in order to walk).Symptoms were considered too mild to warrant treatment with levodopa. The records also noted patient has subdural hematoma. 

According to documentation the patient's ability to perform several ADLs declined. The patient needed only supervision with walking, and did not use an assistive device. The patient's gait was more unsteady; she was using a cane; needed assistance with walking; and had a recent fall during ambulation. Documentation noted that the patient needed extensive (weight-bearing) assistance for transfer toilet; and she had difficulty moving to a standing position unassisted for other type of transfers. Personal care ADLs (bathing, personal hygiene, dressing) all declined.  

Elderly people often experience functional decline as a result of multiple co-morbidities. As noted, the patient's decreasing ability to perform ADLs and IADLs is most likely due to cumulative effects of symptoms related to Parkinsonism, rotator cuff tear, arthritis, foot pain, dizziness.  A serious adverse consequence of her functional impairment, especially for mobility, is higher risk for falls and injuries. Her risk factors include: parkinsonism (Parkinson's disease/parkinsonian syndromes are associated with high risk of falls), arthritis, pain, dizziness, unsteady gait, h/o falls, advanced age, use of medications associated with falls (e.g. antihypertensive drugs). 

The amount of personal care services approved from this review is limited by the number of hours requested; i.e. 49 hours per week. Re-assessment will provide an updated report of the patient's functional status and her need for daily assistance.

Personal Care Services 7 hours per day, 7 days per week, total of 49 hours per week is 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 Services (PCS) 7 hours a day x 7 days a week is substantiated. The insurer's denial is overturned.