Diagnosis: End stage renal disease (ESRD) on dialysis, breast cancer, hypertrophic obstructive cardiomyopathy.

Treatment: Personal care assistance services, total 56 hours per week.

The insurer denied coverage for personal care assistance services, total 56 hours per week.

The denial is overturned.

This is a female with a history of end stage renal disease (ESRD) on dialysis, breast cancer, hypertrophic obstructive cardiomyopathy, hypertension, hyperlipidemia, asthma, osteoarthritis, and glaucoma associated with functional impairment and needs assistance with most daily activities. The patient lives alone. The UAS (Uniform Assessment System) and the service plan indicate she has limited informal caregiver assistance. She relies on personal care assistance (PCA) services for help with activities of daily living (ADL) and instrumental (I)ADLs. She has been receiving PCA 33 hours per week. The patient has end stage renal disease and receives dialysis 3 days per week. The patient requested increase of PCA services to 56 hour per week, which was denied.

The UAS reported patient has frequent urinary incontinence. She takes furosemide 40 mg (milligrams) daily which increases her urine output. The UAS reported patient needs extensive assistance for toilet use and setup help with toilet transfer. However, the patient advocate's letter reported patient needs weight-bearing assistance to transfer on and off the toilet, indicating further decline in function. When she tries to transfer on/off the toilet unassisted, she is at risk for falling. When older people fall in the bathroom, there is increased risk of injury. The advocate's letter noted the aide cleans the patient after toileting because the patient does not have the mobility to clean herself. This may be related to the UAS report of limited ROM (range of motion) of upper extremities. The UAS noted that the patient needed assistance with incontinence care, and it is likely that has not improved, as patient needs assistance with cleaning/hygiene after toileting and with lower body dressing (change of pullups).

MLTC (Managed Long-Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. The patient's need for assistance with IADLs (including meal preparation/service), routine ADLs (morning/evening bathing, dressing, personal hygiene, transfer to bed), and ADLs that occur at unscheduled and recurring times of the day (transfers, walking, toileting, incontinence care) must be considered in the determination of the patient's personal care service hours in order to help prevent adverse health and safety events, such as falls/injury; skin damage (from inadequate toileting and incontinence care); nutritional decline, dehydration.

The UAS indicates the patient has no informal helpers to assist with ADLs and IADLs on a regular basis. As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services indicated to provide assistance with ADLs and IADLs when needed. It is medically necessary and in the best interest for the patient's health to have additional PCA hours.

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 personal care assistance services, total of 56 hours per week is overturned. Medical necessity is substantiated.