Diagnosis: Parkinson's disease, dementia, pubic and acetabular fracture after a fall.

Treatment: Personal Care Assistant (PCA) Services of 7 days times 24 hours (continuous service) per week.

The insurer denied coverage for PCA Services of 7 days times 24 hours (continuous service) per week.

The denial is overturned.

This is a female patient with a past medical history of Parkinson's disease, dementia, thrombocytopenia, hypertension, high cholesterol, diabetes mellitus and a recent pubic and acetabular fracture after a fall. The patient is in hospice care. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY) report, the patient and her daughter were present on the call. This UAS-NY was conducted as a post-hospital assessment. The patient was admitted for a fracture of unspecified parts of the lumbosacral spine and pelvis. She was discharged to Sub-acute rehabilitation. The patient was then admitted to hospice care. Her functional capacity has declined since the recent fall.

The patient's needs are:

- The patient is bed-bound.
- Total dependence for meal preparation, ordinary housework, managing finances, managing medications, phone use, stairs, shopping, transportation, bathing, personal hygiene, dressing her upper and lower body, bed mobility and toilet use;
- Maximal assistance for eating;
- Cognition: There is severe impairment.
- Continence: There is urinary and bowel incontinence. Changed in bed.

An increase in personal care assistant (PCA) services from 24-hour live-in to 7 days times 24 hours (continuous service) per week is being requested.

At issue is the medical necessity of personal care assistant (PCA) services of 7 days times 24 hours (continuous service) per week.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The services are medically necessary as requested.

The patient is bed-bound, totally dependent and incontinent and needs changing in bed. There are no scheduled informal care givers. Nighttime Needs Log shows she needed turning and positioning (T&P) regularly and changing at least once and often more frequently at night.

The provision of diapers and Durable Medical Equipment (DME) such as the hospital bed she has is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" changing diapers regularly and positioning are also necessary.

The patient has repeated unscheduled nighttime personal care needs that support 24-hour care (continuous), as the patient should not be left up to 5 hours with soiled diapers/bed).
The insurer's denial of coverage for the requested Personal Care Assistant (PCA) Services of 7 days times 24 hours (continuous service) per week is overturned. Medical Necessity is substantiated.