Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation.
Treatment: Personal care services level 2 to 4 hours per day 4 days per week; total of 16 hours.
The insurer denied personal care services level 2 to 4 hours per day 4 days per week; total of 16 hours.
The determination is upheld.

The patient has a past medical history significant for hypertension, chronic obstructive pulmonary disease (COPD) and atrial fibrillation.

This review is for the medical necessity of increasing personal care services, level 2 to 4 hours per day, 4 days a week for a total of 16 hours per week. The patient is currently receiving 12 hours a week and has shared hours with his wife for specific activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

Services were denied based upon medical necessity. At issue is the medical necessity of personal care services level 2 to 4 hours per day 4 days per week; total of 16 hours.

The requested health service is not medically necessary for this patient. Additional personal care assistant (PCA) services are not medically necessary. The services provided are adequate to meet the patient's medical needs. The patient has several chronic medical conditions. He uses a cane to ambulate. He has dual services with his wife.

The Uniform Assessment System (UAS) State of New York recommended that the patient have 7.71 hours per week of PCA services for laundry, shopping, meal preparation and housekeeping.

A note from his physician states that the patient's condition is getting worse and he is unable to perform any activity of daily living and needs additional services. It states that the patient has a history of frequent falls, bilateral leg pain, urinary incontinence, hypertension, dizziness, fatigue, heart disease, atrial fibrillation, COPD, wheezing, gout, bronchospasm and lower back pain. It states that the patient is frequently falling and has urinary incontinence and his medical conditions are deteriorating. It also states that the patient is unable to bathe, dress, groom, administer medicine, feed or prep meals independently.

Per a UAS State of New York, the patient was independent with personal hygiene, toilet use, ambulation, uses a cane indoors and outdoors secondary to pain in his legs. The patient is able to transfer from sitting to standing position and ambulate for extended intervals and stand for extended periods of time. There is no noted incontinence. No recent falls were noted.

Another UAS State of New York had similar recommendations.

The denial noted the following: patient is able to ambulate with a cane independently. He is self directing and is able to complete most ADLs independently. Recommendations according to UAs were for 7.71 hours per week. The patient is currently receiving above that number and is also sharing services with his wife.

There appear to be some inconsistencies in regards to the physician assessment versus the nursing evaluation described in the UAS in regards to level of function, especially independent ADLs such as ambulation indoors, grooming, feeding and bathing, dressing, and inability to ambulate. The UAS was done and the physician note was provided. There were no physical therapy or occupational therapy notes available that address this functional decline. There are no new noted significant medical conditions that recently changed such as stroke, heart attack, fracture or malignancy to account for functional changes. Based upon the most recent detailed assessment available for review, it is noted that the patient required a total of 7.71 hours a service a week. Therefore an increase in the requested services is not medically necessary.