Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Wet macular degeneration, Chronic obstructive pulmonary disease, Anterior cruciate ligament tear

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week; (split shift) - a total of 168 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week; (split shift) - a total of 168 hours per week.

The denial is overturned. 

This is a female patient with a medical history of wet macular degeneration, chronic obstructive pulmonary disease - oxygen dependent, hypertension, hyperlipidemia, colitis, anterior cruciate ligament tear, anxiety and insomnia. The patient's daughter has been caring for her overnight, but she is moving and the patient will be alone. The patient was previously approved for Personal Care Aide (PCA) 24 hours-7 days a week, which was declined by the patient because her daughter was to stay with her. The daughter will soon be unavailable.

Per ophthalmology notes, the patient has visual problems. The most recent Uniform Assessment System (UAS) report notes that the patient's functional status is deteriorating. She does not ambulate. Her bed mobility is poor; it was at an independent level in a previous UAS report. She needs turning and positioning (T&P) every 2 hours. She needs assistance with toileting; toilet mobility requires assistance. At her current assistance of 11 hours per day, she will be alone for 13 hours per day, as her daughter is moving. Her functional impairment precludes this.

The insurer did not take adequate consideration of the changes in the patient's status, her degree of impairment, or the impact of her daughter leaving. PCA Level 2: 12 hours per day- 7 days a week (split shift) is medically necessary for this patient. The loss of informal nighttime assistance, the deterioration of functional status, the need for T&P, the need for assistance for bed mobility, ambulation and toilet transfers 24 hours per day, 7 days per week supports 24-hour aide. One aide cannot be guaranteed 5 hours of uninterrupted sleep.

As noted in New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 7/6/16:
 
(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.

(2) Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.

The carrier's denial of coverage for PCA Level 2: 12 hours per day - 7 days a week; (split shift) - a total of 168 hours per week is overturned. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. The medical necessity is substantiated.