Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, colon cancer, hypertension, hyperlipidemia, glaucoma, depression, bladder incontinence. 

Treatment: Personal care aide (PCA) services of 8.5 hours per day, 7 days per week for a total of 59.5 hours per week. 

The insurer denied coverage for personal care aide (PCA) services of 8.5 hours per day, 7 days per week for a total of 59.5 hours per week. 

The denial is overturned. 

The patient has a past medical history of Parkinson's disease, colon cancer, hypertension, hyperlipidemia, glaucoma, depression, bladder incontinence, insomnia, bilateral edema of the lower extremities, neuropathy, osteoarthritis and is legally blind. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, her daughter and social worker were present on the call.  The patient lives with her daughter in a private home. Her daughter is very supportive and involved in all aspects of her care. 

The patient needs assistance with her activities of daily living and instrumental activities of daily living. She is totally dependent for ordinary housework. The patient needs maximum assistance with meal preparation, managing medications, shopping, bathing and dressing her lower body. She needs extensive assistance with transportation, personal hygiene, dressing her upper body, walking, toilet transfer and locomotion. The patient uses an assistive device for locomotion. She had two reported falls. The patient needs limited assistance with managing finances, bed mobility and toilet use. The patient is occasionally bladder incontinent but has complete bowel control. She wears liners and pull ups for her incontinence. She needs supervision, oversight or cueing for eating. 

The patient is independent with phone use.  An increase to personal care aide (PCA) services from 4 hours/day to 8.5 hours per day, 7 days per week for a total of 59.5 hours per week is being requested. 

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. 

The patient has extensive impairments noted above from multiple co-morbidities. She needs assistance with all functions including transfers, locomotion, toilet use, bed mobility. She has had falls and is at risk for more. In this case the provision of assistance is more than just stand-alone supervision. She has informal caregivers but there are 4.5 hours/day when she has no assistance. She needs this for basic functions. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Services of 8.5 hours per day, 7 days per week for a total of 59.5 hours per week is overturned. Medical Necessity is substantiated.