Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis; Diabetes Mellitus; Weakness; Incontinence; Dementia.
Treatment: Personal Care Assistance (PCA) services.
The insurer denied coverage for Personal Care Services (PCS) 12 hours a day, 5 days per week.
The denial is overturned. 

This female patient has a medical history of osteoarthritis, anemia, type 2 diabetes mellitus, hypertension, lumbar radiculitis, osteoporosis, gait disturbance, generalized weakness, incontinence and recurrent urinary tract infections. A Uniform Assessment System (UAS) - New York noted that the patient lives alone on the first floor of an apartment.  She is totally dependent for ordinary housework. The patient needs maximum assistance with meal preparation, managing finances and shopping. She needs extensive assistance with managing medications, phone use, use of stairs, transportation, bathing, dressing her lower body and toilet transfer.  The patient needs limited assistance with personal hygiene, dressing her upper body, walking, locomotion, toilet use and bed mobility. The patient uses an assistive device for locomotion. She has a history of recurrent urinary tract infections. The patient is occasionally bladder incontinent and wears pull ups, often having a wet diaper until her aide comes at 2:30 PM. She also has generalized body weakness, an unsteady gait, physical debility and poor body endurance.  In addition, the patient has generalized joint pain and stiffness, and she takes prescribed medication to manage her pain. The patient's daughter wishes for the patient to remain safely in the community and to continue with assistance with her activities of daily living and instrumental activities of daily living. She has Durable Medical Equipment(DME) and diapers but her mobility is limited so that she cannot manage without help. 

The insurer made their determination at the same time as the record was showing that the patient's level of function had in fact changed from a prior assessment. The patient has some dementia. She is incontinent and has recurrent urinary infections and her ability to transfer, ambulate and toilet as noted by family and the physician are impaired more than requiring limited assistance on a stable basis. She has gait instability and pain as well as weakness. The management of the incontinence is not a planned service. The plan did not give enough weight to changes in the patient's condition or the impact of her degree of impairment. 

As noted above, the patient's functional capacity has worsened and her incontinence needs help managing.  She needs more assistance with transfers and ambulation and toileting. 

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.

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

Based on the above, the medical necessity for Personal Care Services (PCS) 12 hours a day, 5 days per week is substantiated. The insurer's denial should be overturned.