Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pulmonary fibrosis, hypertension, and chronic pain due to spinal stenosis.
Treatment:  Increase Personal Care Aide (PCA) to 90 Hours per Week.

The insurer denied Increase Personal Care Aide (PCA) to 90 Hours per Week.  The denial is upheld.

The patient is an elderly female with multiple medical issues including pulmonary fibrosis, hypertension, and chronic pain in the setting of spinal stenosis. The request is for an increase in Personal Care Aide (PCA) to 90 hours per week from the previously approved 46 Personal Care Aide (PCA) hours weekly.
In an initial adverse determination letter, the plan partially denied the request, allowing for 48 Personal Care Aide (PCA) hours weekly from 46 hours weekly to assist with additional time for toilet transfers. The plan noted that the patient's needs could be met with 48 hours per week. The plan issued a final adverse determination letter which denied the increase in hours, noting that the documentation did not support a further decline or need for additional hours and again noted that the patient's needs could safely and effectively be met by 48 hours per week. In an appeal letter, the patient's provider notes that the patient has worsening pain due to a recent fall. She uses oxygen and needs help with placement of her oxygen. The letter notes that the patient requires "standby assist" to safely navigate around the home and needs "total assistance" due to recent functional decline. A nursing assessment dated 2 months ago notes that the patient is totally dependent for meal preparation and housework. She requires extensive assistance with managing medications and bed mobility. She requires maximal assistance with bathing, personal hygiene, dressing, walking, toilet transfers, and toilet use. She requires limited assistance with eating. She uses a cane to ambulate. A Tasking Tool for last month estimated that the patient requires 49.93 hours per week to address her activities of daily living, with 2 of these hours provided by her daughter, reflecting a total need of 47.93 hours per week of Personal Care Assistance.

The requested health service is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. The request is for an increase in Personal Care Aide (PCA) services to 90 hours per week from 46 hours per week. While the provider note reflects a general functional decline, the plan partially approved an increase to 48 hours per week to account for increased needs with toilet transfers. The submitted documentation does not reflect which specific activities of daily living cannot be completed within this newly approved 48 hours per week. The provider indicates that more help is needed with ambulation, but time for ambulation has already been accounted for in the currently approved hours. Additional hours beyond those currently supplied by the plan would be for safety only. The provider also indicates that additional hours are needed to help the patient "safely navigate throughout her home". However, personal care services are not covered for supervision and safety concerns, per New York State Guidelines. The patient is also noted to have equipment at home to assist with her activities of daily living and keep her safe, including a walker, emergency response system, and incontinence supplies. Based on the available information, the plan's initial denial rationale is appropriate, and 48 hours per week of Personal Care Aide (PCA) hours are sufficient to meet the patient's needs. Thus, the increase in Personal Care Aide (PCA) services to 90 hours per week is not medically necessary.