Diagnosis: Parkinson's disease, dementia, coronary artery disease, congestive heart failure, anxiety disorder and diffuse osteoarthritis.
Treatment: Personal care aide services seven days/week, two 12-hour split shifts
The insurer denied the personal care aide services seven days/week, two 12-hour split shifts.
The denial is overturned.

The patient is a female with a history of Parkinson's disease, dementia, coronary artery disease, congestive heart failure, anxiety disorder and diffuse osteoarthritis. Due to impairments related to her numerous medical conditions, she requires extensive assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of an increase in Personal Care Aide Services to seven days/week, two 12-hour split shift to offer increased ADL assistance.

Yes, the proposed treatment of an increase in Personal Care Aide Services to seven days/week, two 12-hour split shift is deemed medically necessary to offer increased ADL assistance.

Due to impairments related to her numerous medical conditions, she requires extensive assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's physician indicates that due to the patient's need for assistance with nocturnal toileting and history of urinary tract infections and urosepsis, it is medically inappropriate for her to wear an incontinence diaper overnight and not receive toileting assistance with the help of a personal care aide. For these reasons, the currently approved plan of personal care aide services 7 days/week, 24 hours/day live-in is not sufficient to meet the patient's current needs due to the regulated sleeping requirements for this personal care aide from the overnight period. Hence, the proposed treatment of an increase in Personal Care Aide Services to seven days/week, two 12-hour split shift is deemed medically necessary to offer increased ADL assistance.