Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia, insulin dependent diabetes mellitus, major depressive disorder, generalized anxiety disorder. 

Treatment: Personal care aide (PCA) services of 24 hours per day, 7 days per week. 

The insurer denied coverage for personal care aide (PCA) services of 24 hours per day, 7 days per week. 

The denial is overturned. 

The patient has a past medical history of hyperlipidemia, insulin dependent diabetes mellitus, major depressive disorder, generalized anxiety disorder, anemia, coronary artery disease, cardiomyopathy, chronic kidney disease, stroke, congestive heart failure (CHF), gastric ulcer, rectal bleeding, constipation, colon polyp, esophagitis and chronic systolic heart failure. Per details from the New York State Department of Health's Uniform Assessment System (UAS-NY), the patient needs assistance with her activities of daily living (ADLs) and instrumental activities of daily living (IADLs) due to being totally blind in addition to having multiple medical diagnoses. The patient lives alone in a 3 bedroom handicap accessible apartment with a ramp entrance. She was hospitalized after a fall. 

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. 
(2) 
Per the Tasking tool, the patient is totally dependent for ordinary housework. She needs maximum assistance with bathing, dressing her lower body, meal preparation, managing stairs, shopping and transportation. She needs extensive assistance with personal hygiene, dressing her upper body, managing finances, managing medications, phone use, walking, locomotion, toilet transfer and toilet use. The patient is frequently bladder incontinent but is continent of bowel. She uses pads or briefs for her incontinence. The patient uses a wheelchair for locomotion, and she needs maximum help when wheeling outdoors. The patient needs supervision with bed mobility and eating. 

The patient's aide in a letter notes that the patient needs assistance with walking and toileting and she has recently worsened. 

The patient is an elderly female with impairments including total blindness, CHF, poor gait, and diabetic neuropathy. Recent tasking tools as well as physician notes, Certification for home care, and a letter from her current aide, note that the patient needs assistance with all ADLs. Her needs are on a continuous basis.  She is incontinent. She had a recent fall, and her functional capacity has been noted to have declined (as per her aide). There was sufficient evidence to support that 24-hour assistance was considered medically necessary treatment for the patient's condition. 

The health care plan did not act reasonably, with sound clinical judgment or in the best interest of the patient. 

The insurer's denial of coverage for Personal Care Aide (PCA) Services of 24 hours per day, 7 days per week is reversed. Medical necessity is substantiated.