Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Essential Hypertension.

Treatment: personal care aide (PCA) level 2 services of 8 hours per day, 7days per week for a total of 56 hours per week.

The insurer denied coverage for personal care aide (PCA) level 2 services of 8 hours per day, 7 days per week for a total of 56 hours per week.

The denial is overturned.

The patient is a female with a past medical history of bilateral pseudophakia, drusen stage macular degeneration of both eyes, essential hypertension, glaucoma, myocardial infarction, sick sinus syndrome, presence of a cardiac pacemaker, pulmonary embolism, hyperlipidemia, hypertensive retinopathy of both eyes, keratitis sicca, overactive bladder and proximal muscle weakness.  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient lives alone in a 1 bedroom apartment located on the 7th floor of an elevator accessible apartment building.  The patient was hospitalized recently due to a pulmonary embolism.  She was admitted to a Nursing Home for physical therapy and occupational therapy services.  The patient was discharged back to her home. Her overall self-sufficiency has decreased related to increased forgetfulness, increased overall debility and dependence on a caregiver.  A 2019 UAS is also provided.

Needs are: 
-	Total dependence for ordinary housework and managing medications;
-	Maximal assistance for meal preparation, managing finances, stairs, shopping, transportation, bathing and dressing her lower body;
-	Extensive Assistance for personal hygiene, dressing her upper body, walking, locomotion (assistive device), bed mobility, toilet transfer and toilet use;
-	Limited assistance for phone use;
Supervision/Independence for eating.
-	Cognition: Impairment due to dementia. She cannot direct her care.  
-	Continence: There is urinary but not bowel incontinence. 

In a letter, the doctor notes that the patient has dementia and needs more hours of assistance.  In a letter, the physician notes that the patient has worsening problems with positioning in bed, transferring and toileting.  Need for care with multiple other activities of daily living (ADL) is noted. 

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

(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.

When comparing the UAS to that of recent the patient already had extensive needs.  They appear to be worse and increased debility is noted.  Her medical doctor notes onset of dementia and worsening of her functional status, and she has had several hospitalizations.  In the UAS, the patient provided information directly to the evaluator.  Recently, it had to be the son. She cannot turn independently in bed and needs assistance.  The observations of her medical doctor and son at the time of and since the UAS support the need for more hours. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 8 hours per day, 7 days per week for a total of 56 hours per week is reversed. Medical necessity is substantiated.