Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, osteoarthritis, spinal stenosis, chronic anemia, carpal tunnel syndrome, recent right hip fracture, and hearing loss
Treatment: Increase Personal Care Services (PCS) - 24 hours a day, 7 days a week (live-in) For A Total of 91 Hours
The insurer denied: Increase Personal Care Services (PCS) - 24 hours a day, 7 days a week (live-in) For A Total of 91 Hours
The denial is upheld.

The patient is an elderly female with multiple medical issues, including hypertension, osteoarthritis, spinal stenosis, chronic anemia, carpal tunnel syndrome, recent right hip fracture, and hearing loss. The request is for an increase in Personal Care Services (PCS) to 24 hours a day, 7 days a week (live-in) for a total of 91 hours per week. An initial adverse determination 
noted that "plan recommends splitting your schedule into 2 shifts. This will meet your morning and evening needs. Hours can be spread throughout the day to meet all your needs." A final adverse determination noted that the increase to 91 hours of Personal Care Services per week was not medically necessary and further noting that services shall not be authorized if the patient's needs can be met with equipment or supplies. In an appeal letter the patient's advocate argues, "the current authorization does not allow the patient to receive ADL [activities of daily living] assistance throughout the day and night." The letter indicates that the patient needs help getting out of the bed to use the bathroom at night. The letter indicates that there is not enough time with aide to assist in clothing change and personal hygiene before bedtime. In a similar letter the patient's advocate argues that the plan does not take into account that the patient has needs that cannot be scheduled, noting the example of getting to and from the bathroom. The letter argues that durable medical equipment cannot meet the patient's needs. A neurology note indicates that the patient requires at least 12 hours per day, 7 days per week, as, "she is left alone at home for many hours during the day." A nursing assessment from 4 months ago notes that the patient requires maximal assistance for meal preparation, housework, shopping, walking, toilet use and transfer, bathing, and lower body dressing. She requires extensive assistance with managing her medications, personal hygiene, as well as upper body dressing. She requires supervision for eating and bed mobility. An Aide Tasking Tool dated 4 months ago recommended that the total weekly time spent on addressing the patient's needs is 42.5 hours.

The requested health service 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 Personal Care Services (PCS) to 24 hours a day, 7 days a week (live-in) for a total of 91 hours per week from the currently approved 51 hours per week. An appeal letter argues that there is not enough time for the aide to assist with changing the patient's clothes and personal hygiene before bedtime. However, time for housework, meal preparation, personal hygiene, shopping, toileting, and dressing, have already been accounted for in the 51 hours approved by the plan. The tasking tool estimates that 140 minutes per week are required for personal hygiene, 70 minutes for upper body dressing, and 105 minutes for lower body dressing. The appeal materials do not reflect why this allocated time is insufficient. Personal care services are not indicated for supervision and safety concerns, per New York State Guidelines. Based on the available information, the plan's initial denial rationale is appropriate, and 51 hours per week of Personal Care Services (PCS) are sufficient to meet the patient's needs. Thus, the increase Personal Care Services (PCS) (24 hours a day, 7 days a week (live-in) For A Total of 91 Hours) is not medically necessary.