Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Home Health Care.
The insurer denied: increase in Personal Care Worker (PCW) service to 7 days per week, 24 hours per day, continuous care by more than one person - 168 hours.
The denial is overturned.

The patient is a female with past medical history Parkinson's disease, generalized osteoporosis, dementia. This review is for the medical necessity of Increase in Personal Care worker (PCW) to 7 days a week, 24 hours a day continuous care by more than 1 person - for a total of 168 hours per week. The current approved hours of 10 hours daily, 7 days a week, 70 hours. The request was made to increase hours as patient gets confused at night and has falls.

The requested health service/treatment of increase in Personal Care Worker (PCW) service to 7 days per week, 24 hours per day, continuous care by more than one person - 168 hours is medically necessary for this patient
The patient has severe Parkinson's disease, severe dyskinesia with confusion, visual hallucinations and sleep disruption. She requires assistance with all ADLs as she cannot perform any of her daily tasks due to her progressive neurologic disorder. She requires assistance with toileting and toilet transfers and unable to do this independently and requires cuing and reminders to do so, and per review of overnight logs, she requires a caregiver overnight to assist with ADLs and toileting. She also does not have informal caregiver availability for overnight hours.
The requested increase in assistance was not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested hours are medically necessary for this patient.