Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, heart failure, COVID (coronavirus disease)
Treatment: Personal Care Aide (PCA) Level 2, 12 Hours per Day, 7 Days per Week; 12 Hour per Day, 7 Days per Week (Split Shift) - Total of 168 Hours Per Week
The insurer denied the Personal Care Aide (PCA) Level 2, 12 Hours per Day, 7 Days per Week; 12 Hour per Day, 7 Days per Week (Split Shift) - Total of 168 Hours Per Week.
The denial is upheld.

The patient is an elderly female with hypertension, coronary artery disease, complete heart block status post pacemaker placement, heart failure with reduced ejection fraction and hospitalization for COVID pneumonia and heart failure. The request is to increase Personal Care Aide (PCA) Level II hours to 12 hours per day, seven days per week; 12 hour per day, seven days per week (split shift) for a total of 168 hours per week. At the time of the request, the patient had been receiving personal care aide level II: six hours per day - six day(s) per week for a total of 36 hours per week. The Uniform Assessment System (UAS) evaluation completed approximately 3 months prior to presentation reflects that the patient required maximal assistance with meal preparation, managing medications, shopping, toilet transfer, and bathing. She required extensive assistance with personal hygiene and dressing her upper body. She was totally dependent for housework and walking. She could eat with supervision. She required limited assistance with personal hygiene. The patient had a wheelchair and scooter for moving about indoors.

In an initial adverse determination, the plan denied the request for a total of 168 hours per week. The plan partially approved personal care aide services to eight hours per day, seven days per week--for a total of 56 hours per week due to a decline in the patient's functional status. The plan noted that time had been allocated for meal preparation and housekeeping and indicated that an increase to eight hours per day, seven days per week would meet the patient's needs.

The plan issued a final adverse determination, which upheld the decision to deny a total of 168 hours per week and noted that "granting additional hours are not provided when tasks are not being performed...." On appeal, the patient's representative notes that more hours are needed, because the patient is bedbound and needs care in all aspects.

The proposed increase in personal care aide services to a total of 168 hours per week 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 12 hours per day, seven days per week: 12 hour per day, seven days per week (split shift) for a total of 168 hours per week. While the patient was noted to have functional decline in some activities of daily living on the most recent nursing assessment, the plan partially approved an additional 20 hours from an original six hours per day, six days per week (36 hours per week) to account for increased need. The submitted documentation does not reflect that there are activities of daily living which cannot be completed within the 56 hours per week that were approved by the plan. The plan notes that the patient also has appropriate medical equipment in the home, including a personal emergency response system, shower chair, hospital bed, and wheelchair which can assist with the patient's needs. Additional hours beyond those approved would 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 56 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 168 hours per week) is not medically necessary.