Appeal type: Medical necessity
Decision: Overturned

Diagnosis: weakness, ataxia, osteoarthritis.
Treatment: personal care assistance (PCA) services of 24 hour live-in x 7 days per week for a total of 91 hours per week.  
The insurer is denied coverage for personal care assistance (PCA) services of 24 hour live-in x 7 days per week for a total of 91 hours per week.  
The denial is overturned. 

This female patient has a history of ovarian cancer, anxiety, depression, type 2 diabetes mellitus, hypertension, spinal stenosis, weakness, ataxia, osteoarthritis, obesity, hyperlipidemia, cognitive decline, cataracts and vitamin B deficiency.


New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 noted the following:

(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.
(2) Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep....4) Live-in 24-hour personal care services means the provision of care by one personal care aide for a patient who, because of the patient's medical condition, needs assistance during a calendar day with toileting, walking, transferring, turning and positioning, or feeding and whose need for assistance is sufficiently infrequent that a live-in 24-hour personal care aide would be likely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.
Also:
"...s 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 standalone 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 01/24/03 DIVISION: Office of Medicaid Management PAGE 2 GIS 03 MA/003 

The discharge note from Rehab noted that evaluation for eligibility for home health aide services would be done after discharge.

Personal Care Needs Assessment  concluded 44 hours, which is mentioned in the report. This Assessment notes she sleeps through the night. 

A note and order for Home Care from Dr. Lopez of Ophthalmology. She is legally blind and needs 24-hour care. 

A Nighttime Needs Log notes one episode of incontinence/night generally 6-hours after 11 PM. She is cleaned, turned and positioned, and ointment applied. 

In contrast to what was noted in the inital review, it is documented that although the night-time incontinence episodes are infrequent they are documented to occur every night. Due to physical and visual impairments she is unable to clean herself or move independently in bed. The Needs log would indicate that her bed mobility is less than that stated in the first review.  

Given the unscheduled tasks and her inability to perform them the patient's the requested services are medically necessary.


The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the personal care assistance (PCA) services of 24 hour live-in x 7 days per week for a total of 91 hours per week is overturned.  The medical necessity is substantiated.