Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation, essential hypertension, hyperlipidemia, insomnia, osteoporosis and osteoarthritis. 

Treatment: Consumer and self-directed personal assistance services of 84 hours per week. 

The insurer denied coverage for consumer and self-directed personal assistance services of 84 hours per week. 

The denial is upheld. 

The patient is a female with a past medical history of atrial fibrillation, essential hypertension, hyperlipidemia, insomnia, osteoporosis and osteoarthritis. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her daughter were present on the call. The patient lives with her daughter in a private home. 

An increase to consumer and self-directed personal assistance services of 84 hours per week is being requested. 

Needs are: 

1) Maximal assistance for meal preparation, ordinary housework, managing stairs, shopping, transportation and bathing; 2) Extensive assistance for dressing her upper and lower body, walking, locomotion, toilet transfer and toilet use; 3) Limited assistance for managing finances, managing medications, phone use, equipment management and personal hygiene; 4) Supervision/Independence for bed mobility and eating; 5) Cognition: There is mild impairment; 6) Continence: There is urinary and bowel incontinence [UAS states both, Physician Certification notes bladder only]. She uses diapers. 

The patient's daughter is appealing. She notes her mother is getting physical therapy (PT). There are not enough hours of help. She has dementia and gait disorder. She can barely walk and cannot dress herself. 

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." 

Also: 
"... As previously advised, social services districts are NOT required to allot time for safety monitoring as a separate task as part of the total personal care services hours authorized (see GIS 99 MA/013, GIS 99 MA/036). However, districts are reminded that a clear and legitimate distinction exists between "safety monitoring" as a non-required independent stand alone function while no Level II personal care services task is being provided, and the appropriate monitoring of the patient while providing assistance with the performance of a Level II personal care services task, such as transferring, toileting, or walking, to assure the task is being safely completed. WGIUPD GENERAL INFORMATION SYSTEM DIVISION: Office of Medicaid Management PAGE 2 GIS 03 MA/003" 

The request here is to increase hours from 9 hours/day to 12 hours/day. The patient lives with her daughter, who notes that her medical conditions have worsened and her needs have increased. There is no baseline for comparison. The UAS appears to factor in her needs, with hours determined appropriately. The documentation provided for review does not support the need for a change in the number of hours. 

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

The insurer's denial of coverage for the requested Consumer and Self-Directed Personal Assistance Services of 84 hours per week is upheld. Medical necessity is not substantiated.