Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immunodeficiency, type 2 diabetes mellitus, degenerative joint disease, osteoarthritis

Treatment personal care assistance (PCA) of 12 hours per day, 7 days per week for a total of 84 hours per week

The insurer denied coverage for personal care assistance of 12 hours per day, 7 days per week for a total of 84 hours per week

The denial is overturned

The patient is a man with a past medical history of immunodeficiency, type 2 diabetes mellitus, degenerative joint disease, osteoarthritis, dyslipidemia, gastroesophageal reflux disease, falls, COVID-19 (2019 novel coronavirus), daily lightheadedness, headaches, right eye blindness, insomnia, femur fracture, pelvic fracture, bilateral hip replacement, depression and anxiety. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient lives alone on the tenth floor of an apartment building with handicap accessibility. His daughter calls him three to four times per week and visits monthly for medication assistance and to assist with finance management. The patient reported that he needs assistance with his activities of daily living (ADL) and instrumental activities of daily living (IADL).

 He is totally dependent for ordinary housework and stairs. The patient needs maximum assistance with meal preparation, shopping and transportation. He needs extensive assistance with managing finances, managing medications, phone use, equipment management, bathing, dressing his lower body, locomotion, toilet transfer and toilet use. The patient uses a wheelchair or scooter for locomotion. The patient needs limited assistance with personal hygiene and dressing his upper body. He is independent with bed mobility and eating. At the time of a Neuropsychological evaluation, he needed assistance with transferring from a wheelchair (w/c). That evaluation concluded he has mild impairment and needs an aide 12 hours/d (day). 

The patient is frequently bladder incontinent but has complete bowel control. He uses pull ups and chux for his incontinence. 

The patient reported that he fell. 

This reviewer disagrees with the plan's assessment.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:

"(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 blind in the right eye and has peripheral neuropathy, multiple old fractures, some cognitive limitations and other medical conditions listed above. 

He has no informal caregivers except his daughter once a month. He needs assistance across all ADLs except bed mobility. He needs help with transferring to w/c, and this affects his toileting. Given the need for assistance to use a commode or toilet, plus his other impairments, an increase in hours is approved. 

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

The insurer's denial of coverage for the requested Personal Care Assistance of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical Necessity is substantiated.