Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, osteoporosis, dry eye syndrome of the bilateral lacrimal glands.

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

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

The denial is overturned.

This is a female with a past medical history of advanced Parkinson's disease, osteoporosis, dry eye syndrome of the bilateral lacrimal glands, hypertension, osteoarthritis, glaucoma, urinary incontinence and vitamin D deficiency. The patient is wheelchair bound. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient's husband is supportive, and they live in a two-bedroom apartment on the first floor of an elevator building. The patient's diagnosis of Parkinson's disease causes her reduced mobility and tremors and there are signs of dementia. She is totally dependent for ordinary housework. She needs maximum assistance with meal preparation, managing stairs, shopping, transportation, bathing, dressing her lower body, walking, toilet transfer and locomotion. A wheelchair is used for locomotion. Extensive assistance is needed for managing finances, managing medications, personal hygiene, toilet transfers, dressing her upper body and bed mobility. Limited assistance is needed with toilet use. Supervision, oversight or cueing is needed for eating. Setup help only is needed for phone use. Occasional bladder incontinence is noted; the patient is continent of bowels. Diapers are used for her incontinence. The insurer has denied coverage for the personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.  In their Final Adverse Determination letter, they stated that granting additional hours is not provided when tasks are not being performed and for safety monitoring and supervision. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 

(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.

The patient has functional limitations as noted above. She needs extensive assistance with bed mobility, toilet transfers and walking. Provision of services for these functions is beyond supervision and cuing and safety monitoring. She is losing informal caregivers. Multiple physicians note functional and cognitive loss. The patient needs services provided by PCS(Personal care services) 24 hours/day, thus split shift is required. 

The health care plan did not act reasonably and with sound medical judgment or in the best interest of the patient. Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is considered medically necessary for this patient.
	
The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is overturned. Medical necessity is substantiated.