Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, dizziness, fatigue, weakness and unsteady gait. 

Treatment: Personal Care Aide (PCA) Level 2 Services of 6 hours per day, 5 days per week and 4 hours per day, 2 days per week for a total of 38 hours per week. 

The insurer denied coverage for PCA Level 2 Services of 6 hours per day, 5 days per week and 4 hours per day, 2 days per week for a total of 38 hours per week. 

The denial is overturned. 

This is a female patient with a past medical history of hypertension, osteoarthritis, hypercholesterolemia, type 2 diabetes mellitus, urinary incontinence, vertigo, and vitamin deficiency. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient lives alone in a 1 bedroom apartment on the 4th floor of a building with elevator access. The patient needs assistance with her activities of daily living and instrumental activities of daily living due to pain related to osteoarthritis, dizziness related to vertigo, fatigue, weakness and an unsteady gait. 

An increase to personal care aide (PCA) level 2 services of 6 hours per day, 5 days per week and 4 hours per day, 2 days per week for a total of 38 hours per week is being requested. 

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. 

***(2) Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep....4) Live-in 24-hour personal care services means the provision of care by one personal care aide for a patient who, because of the patient's medical condition, needs assistance during a calendar day with toileting, walking, transferring, turning and positioning, or feeding and whose need for assistance is sufficiently infrequent that a live-in 24-hour personal care aide would be likely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep. 

When comparing the more recent UAS to one done prior to that, it is notable that the patient's toileting needs have increased. This is in the context of her having incontinence and needing assistance with transfers, toilet use and ambulation. In this case, safety considerations are in the context of needed Level II personal care services. Safety is not a stand-alone consideration. 

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

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 6 hours per day, 5 days per week and 4 hours per day, 2 days per week for a total of 38 hours per week is overturned. Medical necessity is substantiated.