Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 

The insurer denied increase in Personal Care Assistance (PCA) hours to 24 hours a day live in 7 days a week total 91 hours per week. The denial is upheld. 

The patient is a male with a past medical history significant for dementia, coronary artery disease, ambulatory dysfunction, hypertension, gastroesophageal reflux disease, hyperlipidemia, lower extremity edema, lower back pain and atrial fibrillation. This review is for the medical necessity of increased personal care assistant service hours to 24 hours a day live in, 7 days a week for a total of 91 hours per week. The patient is currently receiving total of 56 hours a week. The additional services were denied based upon medical necessity. 

The health plan's determination is upheld. 

No, the requested health service of increase in personal care assistance (PCA) service to 24 hours a day live-in 7 days per week for a total of 9 hours weekly is not medically necessary for this patient. 

The patient is a male with multiple medical problems. According to the letter from the patient's physician and statement from the patient's representative, the patient has been having progressive problems especially related to his advanced age and memory issues. The patient was noted to have a hospitalization previously, secondary to peripheral vascular disease and ischemic ulcer leading to amputation of one toe. He was subsequently discharged home. Additional services were noted temporary to allow for increased needs subsequent to the hospitalization and amputation. His representative is requesting additional services stating that the patient is unsafe to be left alone secondary to his increasing forgetfulness and dementia.

Services were increased for 8 hours a day 7 days a week for a total of 56 hours a week. Additional services were denied stating the patient does not meet criteria. The patient is alert and oriented to person place and time. He was able to ambulate using a roller walker up to 100 feet. The patient is independent for toilet use. The patient is independent for transfers and bed mobility. He needs little or no hands-on assistance with tasks related to personal hygiene, walking, transferring, toileting, eating or bed mobility. The patient typically wakes at 8 AM and goes to bed at 10 PM. The patient is sedentary for up to 6 hours a day requiring no hands-on assistance. He is noted to sleep through the night. 

Uniform Assessment System (UAS) State of New York were reviewed.
No recent falls were noted. Incontinence is noted to be occasionally incontinent for urine, which is managed by 1-2 pull-ups per day. Bowels are noted to be continent.
Needs assessment done noted that the patient required a total of 6 hours a day 5 days a week for a total of 42 hours a week. 

According to information provided, the patient's medical needs are met with 42 hours a week of service. The patient is currently approved for 56 hours a week of service. The current 56 hours is sufficient to meet the patient's medical needs. The biggest issue of concern is the patient's increasing forgetfulness and generalized medical decline. It is reasonable say that the patient's medical needs, level 1 and level 2 are sufficiently met with 56 hours a week services. Typically, additional services would not be considered medically necessary for safety monitoring or supervision without any concurrent activities of daily living (ADL) or Instrumental activities of daily living (IADL) being provided by PCA. There were no other medical needs addressed in the appeal, the physician statement and the UAS which would necessitate additional services.