Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain and Alzheimer's disease. 

Treatment: Consumer directed personal care assistance services at 40 hours per week.

The insurer denied coverage for consumer directed personal care assistance services at 40 hours per week. 

The denial is upheld. 

This is a female patient with a medical history of spinal stenosis-cervical region, plantar fascial fibromatosis, inflammatory spondylopathy-lumbar region, inflammatory spondylopathy-cervical region, major depressive disorder-recurrent severe without psychotic features, anxiety disorder, panic disorder, mild cognitive impairment, disturbances of skin sensation and Alzheimer's disease. 

Uniform Assessment System documentation noted that the patient lives alone. She needs maximum assistance with meal preparation. She needs extensive assistance with managing medications, managing stairs, shopping, transportation, bathing and dressing her lower body. She needs limited assistance with managing finances, personal hygiene, dressing her upper body, walking, locomotion, toilet transfer and toilet use. She is independent with bed mobility and eating. She uses a cane and walker to ambulate. She reported having a slow and unsteady gait, and problems with balance. She reported that she is suffering from lower back pain which limits her ability to perform activities of daily living and instrumental activities of daily living. She is also not able to bend or stand for a prolonged period of time due to her back pain, and this makes doing tasks in the home difficult. An increase in consumer directed personal care assistance services to 40 hours per week is being requested. Her Medical Doctor notes she has memory and other problems and needs more hours. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 7/6/16 

(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.
...ii) Level II shall include the performance of nutritional and environmental support functions specified in clause (i)(a) of this paragraph and personal care functions.
(a) Personal care functions include assistance with the following:
(1) bathing of the patient in the bed, the tub or in the shower;
(2) dressing;
(3) grooming, including care of hair, shaving and ordinary care of nails, teeth and mouth;
(4) toileting; this may include assisting the patient on and off the bedpan, commode or toilet;
(5) walking, beyond that provided by durable medical equipment, within the home and outside the home;
(6) transferring from bed to chair or wheelchair;
(7) turning and positioning;
(8) preparing of meals in accordance with modified diets, including low sugar, low fat, low salt and low residue diets;
(9) feeding; ...

There is no indication that there has been a fundamental change in the patient's condition. The documentation indicates that the patient needs more companionship for safety issues, services not specifically covered. There is no documentation that establishes that functional capacity has changed. 

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the consumer directed personal care assistance services at 40 hours per week is not substantiated. The insurer's denial is upheld.