Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease status post a percutaneous coronary intervention, hypertrophic obstructive cardiomyopathy.

Treatment: personal care aide (PCA) services level 2 of 16 hours per day, 7 days per week for a total of 112 hours per week.

The insurer denied coverage for personal care aide (PCA) services level 2 of 16 hours per day, 7 days per week for a total of 112 hours per week.

The denial is overturned.

The patient has a history of hypertension, hyperlipidemia, coronary artery disease status post a percutaneous coronary intervention, hypertrophic obstructive cardiomyopathy, aortic stenosis, multifactorial anemia including iron deficiency, inflammation and thalassemia minor, progressive dementia, urinary incontinence and hypothyroidism. 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 3-bedroom private home with no stairs to access. The patient's daughter reported that the patient does not remember her at times due to confusion. 

She is totally dependent for meal preparation, ordinary housework, managing finances, managing medications, phone use and shopping.  The patient needs maximum assistance with managing stairs, transportation, bathing, personal hygiene, dressing her upper and lower body, walking, locomotion, bed mobility, toilet transfer and toilet use. The patient uses an assistive device for locomotion.  She needs supervision, oversight and cueing with eating. The patient received services due to a diagnosis of stercoral colitis. 

The patient is bladder incontinent and occasionally bowel incontinent, and she uses diapers and chux for her incontinence. She has a stage 2 pressure ulcer on her left buttock, and Aquaphor is applied to the site, as ordered by the nurse.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:
 
"(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 is a woman asking for an increase in hours from 53 to 112 per week. She needs maximal assistance with all ADLs (Activities of Daily Living). She has durable medical equipment (DME) but with worsening dementia she cannot remember to use them. She is unable to remember to turn and position (T&P) herself. She has increasing frequency of incontinence and need for unscheduled nighttime services that her daughter cannot keep up with. She already has a bed sore. It is important to keep the skin clean and dry as well as repositioning the patient.

In view of increased needs, the patient request is approved. 

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) Services Level 2 of 16 hours per day, 7 days per week for a total of 112 hours per week is overturned. Medical Necessity is substantiated.