Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation, coronary artery disease, chronic kidney disease, ischemic cardiomyopathy, urinary incontinence. 

Treatment: PCS (personal care services) services to 7 hours per day, 5 days per week. 

The insurer denied coverage for PCS services to 7 hours per day, 5 days per week. 

The denial is upheld. 

The patient is a female with medical history of atrial fibrillation, coronary artery disease, chronic kidney disease, ischemic cardiomyopathy, urinary incontinence, and osteoarthritis. She also has a history of multiple falls. She uses ambulatory devices, has incontinence, and requires assistance with activities of daily living (ADLs). She has received physical and occupational therapy. She received personal care services (PCS) at a frequency of 5 hours per day, 5 days per week. The request is for an increase in PCS services to 7 hours per day, 5 days per week. 

The insurer has denied coverage for PCS services to 7 hours per day, 5 days per week. In their final adverse determination letter, they state the patient is alert and oriented, and makes her needs known. An aide cannot prevent falls or injuries. PCS for companion care or for safety supervision without the direct provision of ADL tasks is not a covered service under the patient's benefit plan. She has durable medical equipment (DME) at home to help her. The patient receives PCS at 5 hours per day, 5 days per week in addition to 10 hours per week of consumer directed personal assistance services (CDPAS). The insurer recommends the patient split the approved aide schedule into 2 shifts to best meet needs. 

The patient's physician is appealing the decision, she states the patient requires assistance and prompting when completing her ADLs because she experiences dyspnea on exertion. She requires assistance for toileting and her physical and cardiac limitations increase her need for assistance, as she is unable to actively participate in her day-to-day activities. She concludes that the patient needs the requested PCS as she is unable to attend to her needs and requires assistance throughout the day. Office note notes she is independent in toileting and transfers. 

The reviewer agrees with the plan's assessment. 

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. 
Documentation is provided to outline the patient's medical problems, the management of which is outside the scope of the aide's tasks. No tasking tools are provided for review, and no information specifies what tasks specifically need additional coverage of 2 hours/day 5 days/week. There is some inconsistency in documentation of what impairments she has. 

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

The insurer's denial of coverage for the request for an increase of PCS services to 7 hours a day, 5 days a week is upheld. Medical necessity is not substantiated.