Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, hypertensive heart disease, chronic heart failure and osteoarthritis.

Treatment: Personal care aide (PCA) level 2 services for a live-in per diem for 24 hours per day.

The insurer denied coverage for PCA level 2 services for a live-in per diem for 24 hours per day. 

The denial is upheld. 

This is a female patient with a past medical history of dementia (Alzheimer's type, advanced with behavioral problems), hypertensive heart disease, chronic heart failure and osteoarthritis. A Uniform Assessment System (UAS) - New York report was done and notes that the patient lives alone in a one bedroom apartment on the 4th floor of a building with elevator access. The patient's daughter reported that the patient's overall self-sufficiency has deteriorated. An increase in personal care aide (PCA) level 2 services for a live-in per diem for 24 hours per day is being requested. Currently, the patient gets 42 hours per week. 
	
As per the New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016:

(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. ...
...4) Live-in 24-hour personal care services means the provision of care by one personal care aide for a patient who, because of the patient's medical condition, needs assistance during a calendar day with toileting, walking, transferring, turning and positioning, or feeding and whose need for assistance is sufficiently infrequent that a live-in 24-hour personal care aide would be likely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep...
...i) Level II shall include the performance of nutritional and environmental support functions specified in clause (i)(a) of this paragraph and personal care functions.
(a) Personal care functions include assistance with the following:
(1) bathing of the patient in the bed, the tub or in the shower;
(2) dressing;
(3) grooming, including care of hair, shaving and ordinary care of nails, teeth and mouth;
(4) toileting; this may include assisting the patient on and off the bedpan, commode or toilet;
(5) walking, beyond that provided by durable medical equipment, within the home and outside the home;
(6) transferring from bed to chair or wheelchair;
(7) turning and positioning;
(8) preparing of meals in accordance with modified diets, including low sugar, low fat, low salt and low residue diets;
(9) feeding; ...
		
Comparison of the past UAS report with that of the more recent UAS report does not indicate that there has been any deterioration in this patient's ability to perform her activities of daily living. There are no specific needs that have changed beyond that for companionship and supervision. Considering that there has been no change in the need for services that would require an increase in PCA level 2 services, her current hours of 6 hours per day, 7 days per week for a total of 42 hours per week are sufficient to meet her needs.

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

The medical necessity for the requested increase in PCA level 2 services for a live-in per diem for 24 hours per day is not substantiated. The insurer's denial should be upheld.