Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, diabetes mellitus, hypertension, hypocalcemia due to hypoparathyroidism, hypoparathyroidism and thyroid disease. 
Treatment: Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The insurer denied coverage for PCA Level 2 Services of 12 hours per day, 7 days per week for a total of 84 hours per week.  The denial is overturned. 

The patient is a female with a past medical history of coronary artery disease, diabetes mellitus, hypertension, hypocalcemia due to hypoparathyroidism, hypoparathyroidism and thyroid disease. The patient is also status post a right below-knee amputation (BKA) on. She has a right lower extremity prosthetic. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her daughter were present on the call. The patient lives with her spouse on the 1st floor of a 2 bedroom private home with stairs to enter. She was hospitalized for the BKA. She later attended rehabilitation. The patient's activities of daily living (ADLs) performance have declined, specifically in her upper body tasks due to the progression of osteoarthritis. She is totally dependent for ordinary housework, managing stairs and locomotion. The patient uses a wheelchair or scooter for locomotion indoors. 

Needs are:  1) Maximal assistance for managing finances, managing medications, transportation, bathing, dressing her lower body, walking and toilet transfer; 2) Extensive Assistance for personal hygiene, dressing her upper body, bed mobility, bed transfers and toilet use; 3) Supervision/Independence for eating; 4) Cognition:  No impairment; and 5) Continence: There is frequent urinary but no bowel incontinence. She wears pull ups. She cannot perform her own toileting with bowel movements. 

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 patient was in Rehab status post BKA. She needs limited assistance with walking and needed assistance with transfers. They recommended 24/7 care. A UAS is done, the day before discharge from the Skilled Nursing Facility (SNF), and then again a month later. There has been deterioration in some functions in that 3-week span. Also, she already needs assistance with bed mobility, bed transfers, ambulation, locomotion, and toileting. This is in the setting of her having incontinence and a recent BKA. Her needs for these basic ADLs are not just for safety and supervision. The increase in hours is approved. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's assessment of the patient's needs. 

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week for a total of 84 hours per week is reversed. Medical necessity is substantiated.