Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD), dementia, delusions.

Treatment: Personal care aide (PCA) services.

The insurer denied coverage for personal care aide (PCA) services.

The denial is upheld.

The patient is a man with a medical history of dementia, delusions and chronic obstructive pulmonary disease (COPD). The patient lives alone in a private home. He has had 6 minor falls in the past 90 days. Memory issues and periods of confusion are noted. Some assistance with activities of daily living (ADLs) is needed.

Needs based on Uniform Assessment System- New York (UAS) are: 

1.	Total dependence for instrumental activities of daily living (IADLs);
2.	Limited assistance for bathing (showers on his own after set-up), upper body and lower body dressing;
3.	Supervision/Independence for bed mobility, personal hygiene, locomotion, toilet use, toilet transfer, walking [no assistive device (AD)].
4.	Cognition: There is impairment. 
5.	Continence: There is no incontinence. 

The UAS notes there are no unscheduled needs. Compared to the UAS dated a few months earlier, personal hygiene has improved from limited assistance to supervision.

The insurer has denied coverage for personal care aide (PCA) services, 7 days per week live-in as not medically necessary. In their Final Adverse Determination, they write that they are reducing the patient's hours from live-in to 7 days per week , 6 hours per day (42 hours per week). Functional capacity has improved since prior assessment. Criteria for medical necessity of live-in services were not met.

Social worker is appealing. In an appeal letter, she writes that basing a decision on a task-based assessment tool is not appropriate for patients who have more continuous or "as needed" requirements. The assessment performed does not reflect the patient's true functional needs and is in violation of Managed Long Term Care (MLTC) Policy 16.07.

The doctor notes that the patient has poor memory from dementia. He cannot be left alone. He exhibits behaviors that could be dangerous to himself.

As per the New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 

(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.
***(2)  Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.
  *** (4)  Live-in 24-hour personal care services means the provision of care by one personal care aide for a patient who, because of the patient's medical condition, needs assistance during a calendar day with toileting, walking, transferring, turning and positioning, or feeding and whose need for assistance is sufficiently infrequent that a live-in 24-hour personal care aide would be likely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.

The patient has memory and judgment problems that place him at risk for wandering and injury and he cannot be left alone. He needs assistance with IADLs. Other than dressing and bathing he needs supervision or is independent in other ADLs. He is continent. Comparison of UAS done shows improvement in personal hygiene to supervision. There are no unscheduled tasks noted in evaluations.

The need for supervision, cuing and safety precautions is clear, but the submitted documentation does not indicate there are other tasks associated with those considerations that fulfill the criteria above.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for personal care aide (PCA) services, 7 days per week live-in is upheld. Medical necessity is not substantiated.