Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Home Health Care: Personal care aide (PCA) level 2 services, 8 hours per day 7 days a week for a total of 56 hours a week

The health plan denied the requested increase in personal care assistant hours. 

The health plan's determination is upheld.

The patient is a female with a past medical history significant for heart failure, glaucoma, osteoarthritis, peripheral vascular disease. This review is for the medical necessity of personal care aide (PCA) level 2 services, 8 hours per day 7 days a week for a total of 56 hours a week. The patient has been currently approved for 4 hours per day 7 days a week for a total of 28 hours a week. At issue is the medical necessity for the requested increase in personal care aide hours.

The requested health service is not medically necessary for this patient.
The Uniform Assessment System (UAS) State of New York was reviewed. Tasking tool notes a total of 28 hours a week with services divided by 7 days. UAS State New York was reviewed. The tasking tool noted a total 24 hours a week of services.
On appeal, per the patient's daughter, it was stated that when the nurse came to determine extra hours my mom has declined due to pneumonia and gout causing her to be bedridden. She is uncomfortable with walker, cannot prepare meals and skips them, needs assistance with stairs secondary to dizziness, pain with walking, needs assistance with bathing, dressing and all activities of daily living (ADLs).  Records were reviewed, which included a progress note for follow up from the hospital for pneumonia. Noted that she "has some fatigue and shortness of breath (SOB) making it difficult to perform ADLs." There was no noted functional assessment of walking ability or other neurological exam included. Recommendations include a request to increase services but no specific recommendation on the amount of services. This evaluation was actually performed prior to the nurses functional assessment in the UAS.
Based upon information provided, specifically the nursing assessments the amount of services are adequate to meet the patient's medical needs. The question of whether the patient has had decreased in mobility subsequent to the evaluation as noted by the patient's daughter is difficult to assess. There were no physician progress notes or other nursing assessment subsequent to the evaluation. Also, the appeal note did not state which additional services she thought that would be medically necessary that could not be performed in the allotted time.
A decline in her functional status is of concern however, when approving services, there must be demonstrated need for ADLs or instrumental activities of daily living (IADLs) above and beyond observation and preventing falls. Services for preventing falls and observation are typically included in the provided services allowed for under the evaluation. Specifically, the aid must be performing a service such as in ADLs or IADLs to be a covered service.
Granting additional hours or not provided when tasks are not being performed and for safety monitoring and supervision, therefore further increasing her PCA services are not medically necessary.