Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Stroke/CVA (cerebrovascular accident)
Treatment: Home Health Care
The health plan denied the requested increase in personal care aide services as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a past medical history significant for a stroke. The patient has subsequent right hemiparesis and hypertension.
The patient is requesting a re-allocation of personal care services. He would like to re-allocate PCA (personal care aide) services to 6 hours per day 6 days per week for a total of 36 hours a week because a friend is now able to assist the patient on Saturdays. The patient is currently receiving 6 hours per day 1 day per week and 5 hours per day 6 days a week for a total of 36 hours a week.
At issue is the medical necessity for the reallocation of Personal Care Aide (PCA) services.

The health plan's determination of medical necessity is upheld, in whole.

No, the requested health service is not medically necessary for this patient. The health plan's determination is upheld, with services to be continued 36 hours a week divided over 7 days.
When the services were determined for the patient, according to the documentation and tasking tool, it was noted that the patient needed 7 days a week of services, due to the specific activities of daily living (ADLs) and instrumental activities of daily living (IADLs) which were medically necessary. These include services for toilet use, continence and eating. Some of the services may not be necessary all days of the week such as housework or meal prep. If the patient needs these services 6 days a week, he will need these on the seventh day, especially toilet use, walking and eating. 
Two recent nursing assessments were reviewed. The patient lives with his friend and her family; his friend is supportive and is involved in his care. His abilities to perform daily activities stayed the same and his needs can be met safely with his current hours of 6 hours per day for 1 day a week and 5 hours per day 6 days a week, totaling 36 hours a week. Granting additional hours are not provided when tasks are not being performed for safety monitoring and supervision, therefore, further increasing his PCA services are not medically necessary.
The Uniform Assessment System (UAS) State of New York assessments  were reviewed, noting that the patient's friend provides help with his ADLs and IADLs every weekend when the aide is not available. This tasking tool noted a total of 30 hours a week of services service/support was necessary, noting 7 days a week. 
The patient is currently receiving 36 hours week of services divided over 7 days a week. He is requesting that these services remain the same in regard to the number of hours, but only to be over 6 days a week. Is not clear from the patient's appeal in regard to the rationale for this discrepancy. It was noted that the patient wanted to go back to church, and he did not feel he needed those hours on Sunday; this may be the reason why the patient is requesting services 6 days a week instead of 7 days a week.
However, after reviewing the tasking tool, it is noted the patient had been recommended 7 days a week of services which are actually being provided. It is reasonable to continue with the 7 days a week with services as previously recommended. If the patient feels that he needs less services than they are actually receiving, this issue could be reviewed separately.