Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Increase in PCA (personal care aide) hours from 7 days per week, 10 hours per day (70 hours per week) to 7 days per week, 24 Hours per day - Split Shift
The insurer denied the increase in PCA hours from 7 days per week, 10 hours per day (70 hours per week) to 7 days per week, 24 Hours per day - Split Shift.
The health plan's determination is partially overturned.

The patient is a male with medical history notable for Parkinson's disease and dementia. The patient is approved for 10 hours per day, 7 days per week (70 hours per week) of personal care services. The patient and his care team requested an increase to 24 hours per day (2-12 hours split shift), 7 days per week (168 hours per week).
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient is bedbound and requires turning and repositioning every 2 hours to prevent pressure ulcer formation. He requires assistance with all activities of daily living (ADL's) as he cannot complete them independently and is a high fall risk. For these reasons, the provider requests split shift 24 hour care for the patient.
The patient's neurologist provided a letter of support. The letter states that the patient has bilateral deep brain stimulators to assist with his Parkinson's symptoms, but he still requires assistance with all activities due to severe gait and balance problems. The physician requests 24-hour care to help the patient with his activities of daily living.
Recent palliative care notes were provided for review. The patient has severe dementia and was referred for hospice care. He is also at choking risk and requires nectar-thickened liquids. They recommended an increase in home healthcare hours.
A Uniform Assessment System (UAS) was completed. The assessment was conducted via teleconference. The patient lives with his spouse in an apartment. He was alert and oriented to person and place only, with periods of forgetfulness and confusion. He is not able to direct his care; his spouse manages his care including finances and medications. For his Instrumental activities of daily living (IADL's), he requires total dependence or maximal assistance for all. For his ADL's (activities of daily living), he requires maximal assistance for all (with the exception of bed mobility, for which he requires limited assistance). He is frequently incontinent of urine and continent of stool. He wears depends for incontinence management. He has had no recent falls. There was no pressure ulcer present.

The requested health service of increase in PCA (personal care aide) hours from 7 days per week, 10 hours per day (70 hours per week) to 7 days per week, 24 Hours per day - Split Shift has not been demonstrated to be medically necessary for this patient. However, the patient should be approved for 24-hour live-in personal care, which is medically necessary for this patient.
The patient has advanced dementia and Parkinson's disease. He requires hands-on assistance to complete all personal care tasks including transfers, toileting, and incontinence care. His care needs are expected to be continuous and unscheduled throughout the day and night. An increase to a 24-hour care aide is medically necessary and reasonable for the patient.
Live-in personal care aides are expected to receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. There is insufficient evidence to demonstrate that the patient's care needs would be extensive enough to prevent a live-in aide from receiving overnight rest. There were no nighttime care logs provided for review and he does not require treatment for an active pressure ulcer. Therefore, the requested increase to 24-hour split-shift care has not been demonstrated to be medically necessary for the patient.