Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopnea, dyspnea on exertion and lower extremity edema. 

Treatment: Personal Care Assistance (PCA) services, Level ll, 9 hours per day, 7 days per week, total of 63 hours per week. 

The insurer denied coverage for Personal Care Assistance (PCA) services, Level ll, 9 hours per day, 7 days per week, total of 63 hours per week. 

The denial is upheld. 

The patient is a male with a medical history of arthritis, bilateral low back pain, stroke x 2, cardiac surgery, diastolic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), paroxysmal atrial fibrillation (PAF), bilateral hip replacements, hypertension and home oxygen requirements.  The patient has orthopnea, dyspnea on exertion and lower extremity edema.  His oxygen saturation dips to 79%.  The submitted Uniform Assessment System (UAS) - New York Comprehensive Community Assessment Report notes chronic pain, dizziness, fatigues, unstable gait, frequent urinary incontinence and fall. This assessment concludes that the patient needs 25 hours/week. 

The patient's physician is appealing.  In an appeal letter the doctor writes that the patient is status post right hip replacement.  Due to complications after his last surgery, he was started on oxygen 24/7.  He is at high risk for falls and has severe difficulty walking and performing activities of daily living (ADLs).  He should have an aide 12 hours/day.  Another treating doctor echoes this in a letter. 

ASSESSMENT:  Reference is made to the following: 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 7/6/16 

(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 only tasking tool submitted for review is over a year old. The request was for increased hours before a total hip replacement and subsequent problems with CHF.  At that time, there was insufficient information on which to make any decision about the need for increased hours looking forward, and the additional information provided in medical doctor (MD) letters addresses issues months later. 

Based on the available information, the plan was correct in its decision.  A new assessment would be warranted to cover any request for change in hours based on the current situation; the MD letters are not specific enough to determine this. 

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

Personal Care Assistance (PCA) services, Level ll, 9 hours per day, 7 days per week, total of 63 hours per week is not medically necessary for this patient. 

The insurer's denial of coverage for Personal Care Assistance (PCA) services, Level ll, 9 hours per day, 7 days per week, total of 63 hours per week is upheld.  Medical necessity is not substantiated.