Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Home Health Care.
The health plan denied the requested increase in Personal Care Assistant hours as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a past medical history significant for hyperlipidemia, multiple sclerosis, osteoporosis, hypertension, urinary incontinence and is wheelchair bound.

This review is for the medical necessity of an increase in Customer Directed Personal Assistant Program (CDPAP) service hours to 60 hours per week.

I recommend upholding, in whole, the health plan's determination of medical necessity.

No, the requested health service is not medically necessary for this patient.
The plan approved 56 hours a week of services. Additional services were denied stating the following: "56 hours a week of services is appropriate to meet her needs, you know yourself and your surroundings, you can express herself until your needs, you know what to do in case of emergency, you wear diapers, and your skin is intact, you have support from your family. You need help with preparing your meals and housekeeping. Your personal assistant helps you with your meals and helps keep her house clean. A pressure mattress was offered but you declined. You need help grooming and keeping your body clean, dressing upper and lower body and moving around. Since her last assessment there has not been a significant change with other activities. Your care worker continues to assist you with activities including bathing and toileting."
The provider note was reviewed and outlines the same needs which are addressed in the Uniform Assessment System (UAS) nursing assessment which are taken into account for the time provided.

The son's statement was reviewed. Patient's son is the formal and informal caretaker. He provides care but states he will not provide informal care for more than 52 hours a week.

The Independent Consumer Advocacy Network (ICAN) report was reviewed when making my final assessment. The patient's physical and mental status were noted both in the ICAN report along with the nursing assessment which outlines the patient's multiple medical problems, including progressive multiple sclerosis, incontinence, and generalized debility.  It lists the patient's needs which were similar to the needs outlined in the UAS Assessment. 

The Uniform Assessment System (UAS) State of New York assessments  were reviewed. Tasking noted a total of 34 hours of personal assistant services needed.

The patient is an elderly female with a past medical history significant for multiple sclerosis who is bedbound/wheelchair bound and requires assistance for most activities of daily living (ADLs) including instrumental activities of daily living (IADLs). There has been a decline in her functional ability noted on nursing assessments. The most recent nursing assessment noted that the patient required a total of 34 hours a week of services; currently she has been approved for 56 hours a week of services which is more than sufficient to meet her needs.

Therefore, I recommend upholding the previous decision; additional services beyond 56 hours a week are not medically necessary.