Diagnosis: Muscle weakness, osteoarthritis, legally blind.
Treatment: Personal Care Assistance (PCA) Services of 12 hours per day, 7 days per week for a total of 84 hours per week.

The insurer denied coverage for PCA Services of 12 hours per day, 7 days per week for a total of 84 hours per week. The denial is overturned.

This is a male patient with a past medical history of congestive heart failure, chronic obstructive pulmonary disease, respiratory failure with hypoxemia, type 2 diabetes mellitus, hypertension, benign prostatic hyperplasia, and legally blind. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and his daughter were present on the call. The patient lives alone in a 3 bedroom multi-level private house with about 4 steps to enter the home. The patient's daughter has been temporarily staying at the patient's home to assist with his needs, but she goes to work before the personal care aide comes to assist. The patient's son is also supportive. The patient needs assistance with activities of daily living and instrumental activities of daily living due to muscle weakness, osteoarthritis and being legally blind. An increase in personal care assistance (PCA) services from 10 hours per day, 7 days per week to 12 hours per day, 7 days per week for a total of 84 hours per week was requested.

The patient has multiple co-morbidities. He is legally blind and has cognitive impairment. He also has extensive functional limitations. He has informal caregivers who cannot commit to being able to provide coverage for his needs 14 hours/day. Due to impaired cognition, blindness, need for nasal oxygen, physical limitations and need for unscheduled toileting, the insurer's denial is overturned.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's interpretation of the patient's needs.

The insurer's denial of coverage for the requested Personal Care Assistance (PCA) Services of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical necessity is substantiated.