Diagnosis: Parkinson's Disease.
Treatment: Personal Care Aide (PCA) Live in services, 7 days a week.

The insurer denied coverage for Personal Care Aide (PCA) Live in services, 7 days a week.

The denial is upheld.

This is an elderly patient living in a 2nd floor apartment with elevator. Son is very involved in care. Cognitive skills are minimally impaired. The physician letter of appeal reports medical conditions and hardship for: transferring, toileting, food preparation, dressing, mobility and bathing. Comparing Uniform Assessment System (UAS) regarding activities of daily living (ADLs), bathing and lower body dressing are similar, personal hygiene is unchanged at limited assistance, frequently incontinent of bladder with some control and continent of bowel are unchanged. No falls in last 90 days. Ambulation currently is noted as very limited but is inconsistent with physical therapy (PT) report noting ambulates 300 feet with rolling walker with assist. In sum, the change over time is not such that these problems cannot be handled with current level of service. There is no need for the 24 hour of coverage. There were no reported safety nor communication issues.

The current records do not provide a medical reason why 7 days a week live in are necessary. There has been no change in medical status. There have been no recent falls. The last admission was a few months ago with subsequent stabilization for return to home. There are no reasons why an awake caregiver at bedside would be required.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Personal Care Aide (PCA) Live in services, 7 days a week is not substantiated.