Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment:  Personal Care Aide (PCA) Level II basic, 2-12 hour shifts per day for continuous care for a total of 168 hours. per week. 

The insurer denied Personal Care Aide (PCA) Level II basic, 2-12 hour shifts per day for continuous care for a total of 168 hours per week.  The denial is upheld.

The patient is an female with a past medical history significant for recent fall, urosepsis, non-ST-Elevation Myocardial Infarction (STEMI), atrial fibrillation (A. fib), right lower extremity deep vein thrombosis (DVT) with pulmonary embolism and mild rhabdomyolysis. The Patient has chronic memory issues secondary to dementia. She was admitted to the hospital for these symptoms and subsequently discharged from skilled care. The patient has been approved for 56 hours a week of services.
This review is for the medical necessity of Personal Care Aide (PCA) level II basic 2-12 hour shifts per day for continuous care for a total of 168 hours per week. Services were denied based upon lack of medical necessity.

The requested health service is not medically necessary for this patient.

The patient was recently hospitalized secondary to a fall associated with a DVT and pulmonary embolism.  She has had progressive decline in cognition along with physical abilities.  She was recently discharged home from skilled services with the following noted evaluation, upon discharge:  1) Transfers require close supervision with a rolling walker, 2)	Able to ambulate 80-100 feet, 3)	Able to maneuver steps with handrails 4-6 steps, 4) Basic activities of daily living (ADLs) require set up with feeding, grooming set up cues as needed.  Bathing touch and partial assist, upper body dressing with touch assist, lower body dressing and shower transfers were supervision and touch assessed
Standing tolerance 8 minutes with a roller walker, 5) 24-hour supervision recommended, and 6) Daughter to stay with her until an aide can be put in place.  Patient has been approved for 56 hours a week.

Her insurance plan denied services based upon the following statements:
We had determined that your current level service of 56 hours per week is sufficient to meet your needs.  You need total assistance with meal preparation and housework, and maximal assistance with shopping.  You need extensive assistance with bathing and lower body dressing.  She needs limited assistance with personal hygiene, upper body dressing, toilet transfer, toilet use, and bed mobility.  You need oversight and cuing with eating.  Personal care service of 56 hours a week is appropriate to meet your assistance needs.

Uniform Assessment System (UAS) State of New York were reviewed.

The patient's documented needs by UAS can be met with 56 hours a week of services. She does have intermittent nocturnal needs. Notes upon discharge therapy services stated that the patient could ambulate 80-100 feet and stand for 8 minutes with a roller walker, which should be sufficient inside of her residence. 

The amount of services provided are adequate to meet the patient's medical needs in the time noted.  Additional services for "prevention of falls" for "monitoring" without services being provided are typically not covered under the terms of the plan.  In order for services to be considered medically necessary, the aide must be performing a service such as medically necessary ADL or Instrumental activities of daily living (IADL).