Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiovascular disease, hyperlipidemia, gastroesophageal reflux disease, osteoporosis

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

The insurer denied coverage for personal care aide (PCA) services of 12 hours per day, 7 days a week for a total of 84 hours per week

The denial is overturned

The patient is a male with a past medical history of hypertension, coronary artery disease, peripheral vascular disease, cardiovascular disease, hyperlipidemia, gastroesophageal reflux disease, osteoporosis, muscle weakness, depression and Alzheimer's disease.  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and his son were present on the call. The patient  lives alone in an apartment.

Needs are: 

-Total dependence for meal preparation, ordinary housework and shopping meal preparation, ordinary housework and shopping;
-Maximal assistance for managing finances, managing medications, phone use and transportation;
-Extensive Assistance for managing stairs, equipment management, bathing, dressing his upper and lower body, walking, locomotion, toilet transfer and toilet use.
-Limited assistance for personal hygiene.
-Supervision/Independence for bed mobility and eating.
-Cognition: 	There is moderate impairment. 
-Continence: 	There is occasional bladder incontinence. He uses diapers. 

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.

Also:
"...s previously advised, social services districts are NOT required to allot time for safety monitoring as a separate task as part of the total personal care services hours authorized (see GIS 99 MA/013, GIS 99 MA/036). However, districts are reminded that a clear and legitimate distinction exists between "safety monitoring" as a non-required independent stand alone function while no Level II personal care services task is being provided, and the appropriate monitoring of the patient while providing assistance with the performance of a Level II personal care services task, such as transferring, toileting, or walking, to assure the task is being safely completed. WGIUPD GENERAL INFORMATION SYSTEM 01/24/03 DIVISION: Office of Medicaid Management PAGE 2 GIS 03 MA/003 "

The patient has dementia as well as assessments such as UAS (uniform assessment system), and is easily distracted. He does not follow instructions well. He has physical impairments leading to extensive functional limitations as noted above. He needs varying degrees of assistance with all functions. This includes transfer from bed, ambulation and toileting. He does not tend to his diapers when they are soiled. The provision of diapers and other DME [durable medical equipment] is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" in www.ncbi.nlm.nih.gov/books6430/ changing diapers regularly is also necessary. His son is not a scheduled informal caregiver.  

He has severe dementia and functional impairment and incontinence. The provision of Level II services is not just supervisory. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the requested Personal Care Aide (PCA) Services of 12 hours per day, 7 days a week for a total of 84 hours per week is substantiated. The insurer's denial is overturned.