Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease and Impaired vision. 
Treatment: Personal Care Aide Level ll PCS [Personal Care Services] Level ll Basic - 15 minutes; 35 hours.
The insurer denied coverage for Personal Care Aide Level ll PCS [Personal Care Services] Level ll Basic - 15 minutes; 35 hours.

The denial is overturned. 

This is a male patient with a medical history of end stage renal disease (ESRD), anemia of chronic disease, hyperphosphatemia, giant cell arteritis with central retinal artery occlusion and anterior ischemic optic neuropathy left eye, nuclear age-related cataract both eyes, glaucoma both eyes (moderate stage), atrial ventricular (AV) fistula, aneurysm and stroke. A telephonic, Uniform Assessment System - New York Comprehensive Community Health Assessment Report notes that the patient lives alone and has been receiving 25 hours of personal care aide (PCA) services, 5 hours a day x 5 days a week. The patient goes to renal dialysis three times a week. Assistance is required for meal preparation, housework, managing finances and medications, stairs, shopping, transportation, bathing, personal hygiene, dressing, locomotion, toilet transfers, toilet use and bed mobility. The patient has dizziness, unsteady gait, pain and fatigue. An increase in hours to 35 hours per week is requested. An Ophthalmology visit notes stable vision (light left eye, large print right). 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016: 
(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.

Based on the review of the medical record and literature, the increased hours of personal care aide (PCA) requested is considered medically necessary for this patient. The patient no longer has any informal assistance from family, due to changes in family circumstances. In this case, proper diet and shopping are essential to this patient's health, given his end-stage renal disease (ESRD) awaiting renal transplant. The patient's eye exam is stable but his vision is greatly impaired and is monocular. In this case, the increase in hours is commensurate with the increased burden on this patient with his activities of daily living (ADLs) and instrumental activities of daily living (IADLs) from loss of family support. 

The Personal Care Aide Level ll PCS [Personal Care Services] Level ll Basic - 15 minutes; 35 hours per week is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Aide Level ll PCS [Personal Care Services] Level ll Basic - 15 minutes; 35 hours per week is substantiated.  The insurer's denial should be overturned.