Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate cancer, vertigo, coronary artery disease, chronic kidney disease, anemia

Treatment personal care aide (PCA) services of an unspecified amount of hours

The insurer denied coverage for personal care aide (PCA) services of an unspecified amount of hours

The denial is overturned

The patient is an elderly with a past medical history of prostate cancer, vertigo, coronary artery disease, chronic kidney disease, anemia, hypotension, hyperlipidemia, insomnia, suprapubic catheter placement and multiple falls. Per an undated letter, the patient was recently hospitalized following a syncopal episode. He needs help with toileting, transfers, ambulating, dressing, bathing and eating. 

Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, his wife, son and personal care aide were present on the call. The patient lives with his wife on the ground floor of a two bedroom cooperative duplex with a handicap ramp. The patient's son reported the patient has increased weakness in the past three to four months. He also has difficulty ambulating due to increased bilateral weakness, unsteadiness and episodic dizziness. The patient had a reported fall episode when he was assisting his wife with transferring to the toilet. The patient denied sustaining any injuries from the fall. The patient's son also reported the patient has an elevated creatinine level and has a pending Nephrology follow up for his renal disease management. 

The patient needs maximum assistance with meal preparation, ordinary housework and shopping. He needs extensive assistance with managing finances, managing medications, managing stairs, transportation, equipment management and dressing his lower body. The patient needs supervision with toilet transfer. The patient needs limited assistance with dressing his upper body, bathing, toilet use and locomotion. He uses an assistive device for locomotion. The patient is independent and needs setup help only with bed mobility, eating, phone use and personal hygiene.  An increase to personal care aide (PCA) services of an unspecified amount of hours is being requested.

He is frequently bladder incontinent but has complete bowel control. The patient uses pull ups for his incontinence.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; note:

"(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 needs as noted above. The approval by the plan is for 8 hours/day 7 days/week, for a total of 56 hours/week. His physician has requested 12 hours/day. The Aide Logs indicate he needs and is getting 12 hours/day. This appears to be adequate for his needs.

The insurer did not act reasonably with sound medical judgment in the best interest of the patient. 12 hours a day, 7 days a week of Personal Care Aide (PCA) Services is warranted. 

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Services of an unspecified amount of hours is reversed as noted above. Medical Necessity is substantiated for 12 hours/day 7 days/week.