Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease and on supplemental oxygen, cervical myelopathy, radiculopathy, diabetes, osteoarthritis.

Treatment: Personal care aide (PCA) services of 10 hours per day, 7 days per week for a total of 70 hours per week.

The insurer denied coverage for personal care aide (PCA) services of 10 hours per day, 7 days per week for a total of 70 hours per week.

The denial is overturned.

The patient has a history of frequent falls, shortness of breath on minimal exertion, diffuse joint pain, congestive heart failure with reduced function class 4, hypertension, chronic obstructive pulmonary disease and on supplemental oxygen, cervical myelopathy, radiculopathy, diabetes, osteoarthritis and peripheral vascular disease.  Per the New York State Department of Health's Uniform Assessment System (UAS-NY), the patient resides with his wife in a one-bedroom apartment in a building with elevator access.  It stated the patient has a new diagnosis of vascular dementia, and his primary care physician and psychiatrist are monitoring his condition. The patient is able to make his needs known, and his wife directs his care and assists with medications and finances. He gets Nurse and PT (physical therapy) visits. 

He is totally dependent for ordinary housework and managing stairs. The patient needs maximum assistance with meal preparation, managing finances, shopping, transportation, bathing, dressing his lower body, walking, locomotion, toilet transfer and toilet use. He is infrequently bladder incontinent but has complete bowel control. The patient uses pull ups for his incontinence. The patient uses an assistive device for locomotion. He and his wife reported ten falls in the last ninety days, and two recent falls resulted in two hospitalizations. One of the hospitalizations required the patient to have stitches on his head.  

He needs extensive assistance with managing medications, phone use, personal hygiene and dressing his upper body. The patient needs limited assistance with bed mobility and eating. 

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

"(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 health Plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient has increased needs. His physician attests to worsening cognitive and physical function. Compared to the past, he now needs maximum assistance with all ADLs (activities of daily living) except bed mobility. Increased needs are not just for safety monitoring. He needs maximal assistance with locomotion, transfers and toilet use and any additional safety monitoring is provided with these services. 
   
The insurer's denial of coverage for the requested Personal Care Aide (PCA) Services of 10 hours per day, 7 days per week for a total of 70 hours per week is reversed. Medical necessity is substantiated.