Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, congestive heart failure, gout, acute kidney infection, chronic obstructive pulmonary disease, osteoarthritis, dementia, sun downing, diabetes, hypertension, pneumonia

Treatment: Personal Care Aide (PCA) Level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The insurer denied coverage for PCA Level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The denial is overturned

The patient is male with a past medical history of Parkinson's disease, congestive heart failure, gout, acute kidney infection, chronic obstructive pulmonary disease, osteoarthritis, dementia, sun downing, diabetes, hypertension, pneumonia and left hip surgery with an internal fixation. He was hospitalized with pneumonia. The patient was sent home with a urinary catheter due to urinary retention. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and personal care worker were present during the assessment. The patient resides in a 2 bedroom apartment with his wife, and there are 4 steps leading to the front door.

Needs are: 

-	Total dependence for meal preparation, ordinary housework, shopping and transportation;
-	Maximal assistance for managing finances, managing medications, stairs, bathing, personal hygiene, dressing his upper and lower body, walking, locomotion, toilet transfer and toilet use;
-	Extensive Assistance for bed mobility and eating;
-	Cognition: There is mild impairment. 
-	Continence: There is urinary but no bowel incontinence.  He has a Foley for urinary retention.

The insurer has denied coverage for the personal care aide (PCA) Level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week. In their Final Adverse Determination letter, they stated the request to increase services was denied because it was not medically necessary, and the patient did not meet the criteria. 

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 patient has extensive impairments.  As noted above, during the period between UAS, the patient deteriorated.  He has become weaker since.  The Appeal notes states he needs assistance with toileting; he is actually noted to need extensive-maximal assistance with bed mobility, transfers, walking, and toileting.  He cannot turn and position himself in bed.  He needs assistance with toileting and cleaning after a bowel movement; he could otherwise be in a soiled diaper/pull-up for hours.  

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plans interpretation of the patient's needs and impairments.

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is reversed. Medical necessity is substantiated