Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unspecified intellectual disabilities and attention deficit hyperactivity disorder (ADHD).
Treatment: personal care services (PCS).
The insurer denied coverage for personal care services.
The denial is upheld.

This is the case of a male patient with a past medical history of unspecified intellectual disabilities and attention deficit hyperactivity disorder (ADHD). Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and his mother were present on the call. The patient is Spanish speaking, and he lives with his parents and two minor siblings. Due to his diagnosis, he needs assistance and supervision with his activities of daily living (ADLs) and instrumental activities of daily living (IADLs). It was documented that the patient's diagnosis is monitored, and there is no active treatment. The patient's mother is his primary caregiver. Per the patient's mother, the patient can state his basic needs in Spanish. He cannot be left home alone, and he needs help with his personal care. The patient can be angry and anxious if people do not understand him. He also has a poor attention span and difficulty with learning. 

The patient is totally dependent for managing finances. He needs maximum assistance with meal preparation, ordinary housework, managing medications, phone use, shopping, transportation, and equipment management. The patient needs extensive assistance with bathing. He needs limited assistance with personal hygiene, dressing his upper and lower body and eating. The patient needs supervision and oversight/cueing for stairs, walking, toilet transfer, toilet use, bed mobility and locomotion. He has complete bladder and bowel control, and there were no episodes of incontinence reported. The patient walks without an assistive device. There were no episodes of wandering reported. Personal care services are being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 

(a) Definitions and scope of services.
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse. 

The New York State Department of Health's Uniform Assessment System (UAS-NY) and Request for Home Care (M11Q form) do not document any physical functional impairments. The Request for Home Care notes that supervision is needed. He functions within the community and goes to school.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient. The reviewer agrees with the plan's assessment. The patient does not meet criteria for personal care services.  

The insurer's denial of coverage for the requested Personal Care Services is upheld. Medical necessity is not substantiated.