Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bladder Cancer, Lung Cancer
Treatment: Personal Care Aide (PCA) Level 2: 6 hours per day - 5 days a week - a total of 30 hours per week
The insurer denied Personal Care Aide (PCA) Level 2: 6 hours per day - 5 days a week - a total of 30 hours per week.
The determination is overturned.

This is a male patient with a history of bladder cancer, lung cancer, prostate cancer, hypertension, aortic stenosis, heart failure, back pain, osteoarthritis of the ankle and foot, history of falls, and urinary incontinence. He lives with his sister. The patient was previously approved for 17.5 hours per week. The patient and his care team requested personal care assistant (PCA) services for 6 hours per day, 5 days per week (30 hours per week). 
A video Uniform Assessment System (UAS) was completed.  The patient was assessed at total dependence with the task of ordinary housework; maximal assistance for meal preparation, shopping, bathing, dressing upper body, and dressing lower body; extensive assistance for managing medications, stairs, transportation, walking, locomotion, transfer toilet, toilet use, and bed mobility; limited assistance for managing finances, personal hygiene, and eating; and setup help only for phone use. Durable medical equipment at home includes a personal emergency response services (PERS), cane, shower chair, shower grab bar, walker, and incontinence supplies. A tasking tool was used to determine that he requires 27.5 hours of aide service per week.
The patient's primary care physician (PCP) provided a letter of support. His PCP requested an increase in PCA services due to worsening of some of his chronic medical conditions. 
The patient's advocate provided a letter of support. Per his advocate, his most recent UAS showed that his activities of daily living (ADL) status declined and self-sufficiency deteriorated in the past 90 days. His advocate states that he needs assistance to perform ADLs of ambulation, transfer, toilet, turning and positioning. Per his advocate, his Plan did not offer any explanation as to why his authorized care hours per week (17.5 hours) is less than the Plan's own task-based tool assessment (27.5 hours per week). At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 6 hours per day - 5 days a week - a total of 30 hours per week.
Personal Care Aide (PCA) Level 2, 6 hours per day - 5 days per week (total of 30 hours per week) is medically necessary.
There is documentation in the UAS of the patient requiring at least extensive assistance with the tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan did not document a plan to meet these unscheduled and unpredictable care needs. There is documentation from the patient's PCP of medical necessity of increased PCA services and decline in patient's ability to perform ADLs. In addition, the Plan's task tool indicates that the patient requires more hours of care per week to meet tasks than are currently approved. The patient lives with his sister and therefore has informal support. However, per NYCRR 505.14, the plan cannot assume that the informal support person can provide all needed care outside of the approved PCA hours as informal supports must be voluntary. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with ADLs.