Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation, spinal stenosis, advanced macular degeneration, hearing loss, unsteady gait

Treatment PCA (personal care aide) level 2 services of 5.5 hours per day, 7 days per week for a total of 38.5 hours per week

The insurer denied coverage for PCA level 2 services of 5.5 hours per day, 7 days per week for a total of 38.5 hours per week

The denial is overturned

The patient is an adult female with a past medical history of atrial fibrillation, spinal stenosis, advanced macular degeneration, hearing loss, unsteady gait, bilateral carpal tunnel syndrome and osteoarthritis. Per a letter from physician, the patient's diagnosis of advanced macular degeneration has extremely limited her vision, which affects her ability to perform activities of daily living (ADLs). It is stated that the patient cannot live unassisted. Per a letter, the patient is at risk for falls and ambulates with a walker. The patient has a history of a fall. She fractured her foot and needed soft cast. The patient is no longer able to be independent, and she needs an aide 7 days a week. Another letter stated that the patient has diagnosis of severe bilateral carpal tunnel syndrome which constricts her basic abilities. 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 alone in a private residence with stairs. Her daughter and son are supportive and involved in her care. 

The patient requires assistance with her ADLs and instrumental activities of daily living (IADLs) due to her diagnosis of osteoarthritis, which causes fatigue, stiffness, limited range of motion and unsteady gait. The patient also has low vision and depth perception caused by her diagnosis of macular degeneration. She is totally dependent for shopping. The patient needs maximum assistance with meal preparation, ordinary housework, managing medications and managing stairs. She needs extensive assistance with managing finances, transportation, and bathing. The patient needs limited assistance with dressing her upper and lower body, walking, locomotion, toilet transfer and toilet use. The patient uses an assistive device for locomotion. The patient is independent in bed mobility and is independent and needs setup help only with eating and personal hygiene. The patient is frequently bladder incontinent but has complete bowel control. She wears liners for her incontinence. There is no cognitive impairment. No falls or hospitalizations were reported within the past 90 days of this UAS-NY. 

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 patient is a woman with physical and visual impairments that are chronic. Assistance with multiple ADLs is needed as above, and she has been receiving services 4.5 hours/day 6 days a week. The patient's impairments would necessitate extending that coverage to 7 days/week, as her needs are persistent and daily. 

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

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 5.5 hours per day, 7 days per week for a total of 38.5 hours per week is overturned. Medical necessity is substantiated.