Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory System-Strokes
Treatment: Home Health Care-Personal Care Aide (PCA)
The increase in PCA hours was denied as not medically necessary.

 The reviewer has upheld in whole the health plan's determination.

Patient has a past medical history significant for hypertension, stroke, hyperlipidemia, gastroesophageal reflux disease, dementia, and gait abnormality. This review is for the medical necessity of personal care level to aid services, 12 hours a day 7 days a week split shift for a total of 168 hours a week.

Additional services are not medically necessary. Additional services are for safety and supervision. Patient has multiple medical problems including advancing age, failing health, cerebrovascular disease along with gait abnormality and memory problems including dementia.

Services were denied based upon the following rationale:
Patient needs limited assistance for dressing upper body, personal hygiene, and bed mobility. Patient needs extensive assistance for dressing lower body, walking, locomotion, bathing, toilet transfer and toilet use. Patient needs maximal assistance for meal preparation and medication management. Time has been allotted for meal preparation, laundry, and housework. Patient has shower chair, grab bar walker and wheelchair at the home for assistance with personal care needs. Granting additional hours are not provided when tasks are not being performed, therefore further increasing her Personal Care Aide (PCA) services are not medically necessary.
Uniform Assessment System (UAS) State of New York was noted, and reviewed, this was a telephonic survey secondary to Covid (Coronavirus Disease) 19.
Statement from patient's physician stating that the patient has a gait disorder and falls frequently and is at high risk for continued falls, statement from patient's primary care physician, hospital admission for urinary tract infection, Progress notes on  and states the patient is alert and oriented (times) 3 and has normal gait. Progress note, Frequent falls, at night when going to the bathroom, an aide stays with her at night. Gait was not tested otherwise neurological exam appeared intact Physical therapy recommended 247 care upon discharge from rehabilitation.
Patient clearly has advancing medical problems including her age, neurological problems from her stroke along with dementia and gait abnormality however, there were no noted services which were requested that needed to be provided in the nocturnal hours. The services in the nocturnal hours were for safety monitoring and supervision. Prevention of falls if the patient inadvertently gets up and tries to walk to go to the bathroom. Patient has 42 hours a week which were assessed by the UAS to be necessary for her activities of daily living (ADLs)  and Instrumental activities of daily living (IADLs).
Additional services for "prevention of falls" for "monitoring" without services being provided are typically not covered. For services to be considered medically necessary, the aid must be performing a service such as medically necessary ADL or IADL.
Recent documentation of hospitalization for a urinary tract infection (uti) with obstructive uropathy with deterioration in health status and referrals to hospice. There were no new reports regarding recommendations for additional aide service which would be medically necessary for the patient above and beyond those documented with the previous nursing assessments / UAS.