Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Aortic stenosis status post transcatheter aortic valve replacement, hypertension, and diabetes
Treatment: Increase in Personal Care Aide (PCA) services to 6 hours per day, 7 days per week and 12 hours per day, 7 days per week for a total of 126 hours per week
The insurer denied: Increase in Personal Care Aide (PCA) services to 6 hours per day, 7 days per week and 12 hours per day, 7 days per week for a total of 126 hours per week
The denial is upheld.

The patient is an elderly female with multiple medical comorbidities including aortic stenosis status post transcatheter aortic valve replacement, hypertension, and diabetes who was initially receiving Personal Care Aide services six hours per day, seven days per week for a total of 42 hours per week. The request was for an increase in Personal Care Aide (PCA) services to six hours per day, seven days per week and 12 hours per day, seven days per week for a total of 126 hours per week. 
Uniform Assessment System (UAS) evaluation completed recently reflects that the patient requires maximal assistance with bathing, toilet transfers, meal preparation and shopping. She requires limited assistance with personal hygiene and eating. She requires extensive assistance with taking medications, walking, and dressing. She is totally dependent for housework. The documentation reflects that the plan decided that the increase in hours was not approved, and the hours would remain the same (six hours per day, seven days per week, for a total of 42 hours per week). In making this decision, the plan notes that the approved hours were appropriate and safely meeting the patient's needs. In an adverse determination letter, the plan reiterated the rationale and noted that the hours would remain the same. 
According to the submitted appeal, the patient requires an additional four hours of personal care aide, as she cannot stand without support, needs help carrying food, and needs help getting into bed. "No one is there to help with dinner time, bedtime." Additional appeal information from the patient's son argues that the patient needs personal aide services hours from 4PM to 8PM, as the patient is unsafe without additional help and that she cannot hear well.

The proposed increase in personal care aide services is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. The request is for an increase in home/personal care to 126 hours per week from 42 hours per week. The submitted documentation does not reflect that there are activities of daily living which cannot be completed with the 42 hours per week that were approved by the plan. While the patient's family notes that the patient cannot obtain food on her own, the plan notes that time has already been allotted for meal preparation in the existing 42 hours and that the patient is able to feed herself once meals are provided. The plan notes that the patient also has appropriate medical equipment in the home, including a personal emergency response system, shower chair, shower grab bar, cane, and walker which can assist with the patient's needs. The patient's son notes on appeal that the patient is unsafe without additional hours. Additional hours beyond those approved would thus be primarily for supervision and safety concerns. However, personal care aide services cannot be approved for the purpose of supervision, per New York State Guidelines. Based on the available information, the 42 hours per week of personal care services are sufficient to adequately meet the patient's needs. Thus, the proposed treatment (i.e., increase in Personal Care Aide services to 126 Hours per Week) is not medically necessary.