Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary heart disease, hypertension, hyperlipidemia, hypothyroidism, spinal stenosis, pruritus, gastroesophageal reflux disease, osteoarthritis, COVID-19 and pneumonia due to COVID-19.

Treatment: Personal care aide (PCA) services, level 2 of 12 hours per day, 7 days a week, 12 hours per day, 7 days a week (split shift), for a total of 168 hours per week

The insurer denied coverage for PCA services, level 2 of 12 hours per day, 7 days a week, 12 hours per day, 7 days a week (split shift), for a total of 168 hours per week

The denial is upheld

The patient is female with a past medical history of coronary heart disease, hypertension, hyperlipidemia, hypothyroidism, spinal stenosis, pruritus, gastroesophageal reflux disease, osteoarthritis, COVID-19 and pneumonia due to COVID-19.  The patient was admitted for sub-acute rehabilitation status post COVID-19 and pneumonia.  The patient had limitation of activities due to disability, muscle weakness and abnormal posture.  A New York State Department of Health's Uniform Assessment System (UAS-NY) dated notes that the patient lives alone in a one bedroom apartment on the 13th floor of a building with elevator access.  The patient experiences pain in her back, bilateral feet and legs that are relieved with medications.  The patient has shortness of breath with moderate activities such as walking.  The patient also has fatigue, stiffness, and dizziness, limited range of motion, poor balance, an unsteady gait and difficulty bending down.  She is totally dependent for ordinary housework.   The patient needs maximum assistance with meal preparation, shopping, transportation, bathing, dressing her lower body, toilet transfer, walking and locomotion.  The patient uses an assistive device for locomotion.  The patient needs extensive assistance with managing medications, managing stairs, personal hygiene, dressing her upper body, bed mobility and toilet use.  The patient is occasionally bladder incontinent but completely bowel continent.  The patient uses incontinence supplies.  The patient needs limited assistance with eating and managing finances.  The patient needs setup help only with using the phone. The assessment done notes that the patient is moderately safe at home after setup for activities of daily living (ADLs). 

An increase to personal care aide (PCA) services, level 2 of 12 hours per day, 7 days a week, 12 hours per day, 7 days a week (split shift), for a total of 168 hours per week is being requested for this patient, and this request is due to the patient's fatigue, dizziness and pain. 

The New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 outlines the Definitions and scope of services.

The UAS were reviewed, as were the assessment notes.  The level of impairment noted in the recent assessment is not significantly different from that noted early in the early assessment. The patient's level of continence and bed mobility are similar, and the patient's level of ambulation is also similar (i.e., maximal assistance). In the interval, the patient had COVID-19 but has recovered.  The factors taken into account in assessing hours months prior are similar to those present now.  There are no new tasks that are required.  There is no support for an increase in coverage to 168 hours per week for this patient. 

The requested PCA services level 2 of 12 hours per day, 7 days a week, 12 hours per day, 7 days a week (split shift), for a total of 168 hours per week is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the requested personal care aide (PCA) services level 2 of 12 hours per day, 7 days a week, 12 hours per day, 7 days a week (split shift), for a total of 168 hours per week should be upheld. The medical necessity is not substantiated.