Appeal type: Medical necessity
Decision: Overturned

Diagnosis: osteoarthritis

Treatment PCA (personal care aide) level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The insurer denied coverage for PCA level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The denial is overturned 

The patient is a female with a past medical history of vascular dementia, hypertension, hypothyroidism, obesity, unspecified pain, osteoarthritis of the knee, abnormality of gait and mobility, urinary incontinence, and vitamin D deficiency. 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 in a private home with her husband.  Her primary diagnosis of osteoarthritis and bilateral knee pain, dizziness, difficulty walking and unsteady gait limit her ability to perform tasks without assistance. 

She is totally dependent for meal preparation, ordinary housework, managing finances, shopping, and transportation. The patient needs maximum assistance with managing medications and managing stairs. She needs extensive assistance with equipment management, bathing, dressing her upper and lower body and toilet transfer. The patient needs limited assistance with walking, toilet use, bed mobility and locomotion. She uses an assistive device for locomotion. The patient needs supervision, oversight or cueing with phone use, personal hygiene and eating.  

The patient is infrequently bladder incontinent and bowel continent. 

An increase to personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is being requested.

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 UAS (uniform assessment system) was done a year ago. She already needed assistance with toileting and transfers. The patient's medical doctor more recently notes worsening cognitive function. She has weakness and gait instability. She needs frequent incontinence care. She is losing informal caregivers. Due to physical and cognitive problems she cannot care for her basic needs reliably. Her needs are 24-hour and unpredictable. 

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

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; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is reversed. Medical necessity is substantiated.