Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Home Health Care. 
The insurer denied: Increase in PCA services to 12 hours/day x 7 days/week. 
The denial is overturned in whole. 

The patient is a female with past medical history of anorexia, vitamin D deficiency, hyperlipidemia, hypertension, age related osteoporosis, cardiac arrhythmia, folate deficiency anemia, mood disorder, gastroesophageal reflux disease (GERD), urinary incontinence, insomnia, depression, neuropathy, osteoarthritis, and dementia who had been assigned patient care assistance (PCA) services 8 hours/day x 5 days, 4 hrs./day x 2 days to total 48 hours/week. 

The provider appealed adverse decision and the family appealed the adverse decision. The insurer provided a letter stating the patient's provider noted the patient needs additional assistance due to her ongoing chronic medical conditions and per the New York State Department of Health (NYSDOH) personal care service criteria, a medical provider who completes the order form must not recommend the number of hours of services that and individual should be authorized to receive. This letter also stated the patient has a shower chair, grab bars, and a commode to assist her care and has a walker to help her move about her environment. In addition, the insurer stated giving additional aide services does not prevent falls or injuries and her approved aide hours schedule can be spilt to better meet her needs. The plan suggested following up with her doctor regarding the need for physical therapy to help her gain strength and help her move around her environment safer. This letter noted upon review of additional information the plan stands by the decision to uphold the denial of increased hours.
The subject under review is the medical necessity for personal care services, 12 hours a day, 7 days per week medically necessary for this patient. 

The health plan's determination is overturned, in whole. 

The universal assessment tool performed noted the patient needed some assistance with tasks of locomotion, walking, transfer toilet and toilet use. The information provided indicated the patient is alone for a period of time when the aide leaves and when informal helper is available. The patient has unscheduled needs over a span of time when she is alone which the plan did not take into consideration. 

The telephonic assessment underestimated the patient's care needs as it was noted she was independent with eating however notes from assessment indicate she has not been eating her meals and requires queueing to eat. In addition, the assessment noted the patient is unable to put on or take off pullup and requires assistance with toileting schedule but was assessed at limited assistance for personal hygiene and toilet use. The increase in PCA service hours is not solely for safety and supervision but to assist the patient with supervision and cognitive prompting to assure the safe completion of one or more ADL's and IADL's. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home. If the patient attended PT with improvement in locomotion and walking, she would still need assistance with unscheduled needs of toilet use and incontinence cares/personal hygiene. The patient's medical provider documented medical necessity of increase in PCA service hours and although not able to specify the number of hours, was able to specify the hours the patient did not have an informal helper to assist with her PCA care needs.