Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blindness, prior stroke
Treatment: Increase Personal Care Services (PCA) to 9 Hours, 5 Days Per Week
The insurer denied: Increase Personal Care Services (PCA) to 9 Hours, 5 Days Per Week
The denial is upheld.

The patient is an elderly female with multiple medical issues including blindness, prior stroke, anemia, hypothyroidism and hypertension. The request is for an increase in Personal Care 
Services (PCS) to 9 hours a day, 5 days a week from the currently approved 7 hours a day, 5 days a week. The plan issued a final adverse determination letter which denied the increase in hours, noting that a tasking tool had estimated the need of 34.5 hours over 7 days to meet the patient's needs. The plan further notes that services such as physical therapy, occupational therapy, transportation, and referral to community based organization for visually impaired were available to help address the patient's needs. In an appeal letter, the patient's daughter argues that the patient needs help with dressing, bathing, toilet transfer and use, walking, and bed mobility, meal preparation, and household tasks. She says that her mother needs the assistance of another person for this to ensure safety and prevent falls. The physician order for services notes that the 
patient has visual impairment and will attempt to ambulate by herself to void, which could result in falls with injury and possible hospitalization. The provider notes that patient is frailer and 
becomes disoriented. A nursing assessment dated 2 months ago notes that the patient is totally dependent for meal preparation and housework. She requires extensive assistance with managing medications, shopping, bathing, lower body dressing, walking, toilet transfer, bed mobility. She requires limited assistance with personal hygiene, upper body dressing, and eating.

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 9 hours a day, 5 days a week from the currently approved 7 hours a day, 5 days a week. The submitted appeals documentation does not 
reflect which activities of daily living cannot be completed within the currently approved 35 hours per week. In the appeal letter, the patient's daughter argues that the patient needs assistance with dressing, bathing, toilet transfer and use, walking, and bed mobility, meal preparation, and household tasks. However, time for housework, meal preparation, personal hygiene, shopping, toileting, and dressing, have already been accounted for in the 35 hours per week approved by the plan. Additional hours beyond those currently supplied by the plan would be for safety only; the patient's daughter also indicates that additional hours are needed to keep the patient safe due to fall risk. However, personal care services are not covered for supervision and safety concerns, per New York State Guidelines. The patient is also noted to have equipment at home to assist with her activities of daily living and keep her safe, including a walker, grab bars, shower chair. The plan further offers additional services, such as physical therapy, occupational therapy, transportation, and community based services for the visually impaired to assist with the patient's needs in addition to the approved hours. There is no 
indication that the patient has tried and failed these supplemental services to address safety and activities of daily living. Based on the available information, the plan's initial denial rationale is appropriate, and Personal Care Services of 7 hours a day, 5 days a week are sufficient to meet the patient's needs. Thus, the 
increase in Personal Care Services Care to 9 hours a day, 5 days a week is not medically necessary.