Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Respiratory Disorder. 
Treatment: Home Health Care. 
The insurer denied personal care hours 59.5 hours per week. The denial is overturned in part. 

The patient is a female with a past medical history significant for anxiety disorder, hyperlipidemia, vocal cord polyps, chronic obstructive pulmonary disease (COPD), osteoarthritis, lumbar radiculopathy, morbid obesity, sleep apnea, diabetes mellitus and urinary incontinence.
This review is for the medical necessity of consume a program, 8.5 hours per day 7 days a week for total of 59.5 hours a week. Services were denied based on medical necessity The subject under review is the medical necessity for 59.5 hours per week.

The requested service is medically necessary, in part. The patient requires additional services secondary to health decline noted on evaluation. However, 6.5 hours per day for a total of 45.5 hours a week is medically necessary. Services were denied by her insurance stating the following. Requested an appeal because you stated you need additional assistance with toileting, incontinence care, making the bed when she gets soiled, giving you food and snacks during the night, reapplying her continuous positive airway pressure (CPAP) machine as well as massaging her legs due to cramps. You require set up help for eating. She required limited assistance for dressing upper body and personal hygiene. You require extensive assistance for bed mobility and toilet use. You require maximal assistance for dressing lower body, walking, locomotion, bathing, toilet transfer, meal preparation and medication management. You are totally dependent for housework. You are able to direct her own care.
Time has been allotted for meal preparation, laundry, housework. You have a shower grab bar, walker, and incontinence supplies near home to assist you with a personal care need. Based on your most recent evaluation your personal care needs can continue to be met with 4.5 hours a day 7 days a week of services. Grant in additional hours is not provided when tasks or not being performed and are for safety monitoring and supervision, therefore further increasing your services is not medically necessary.
The patient currently resides in a 2-bedroom apartment with her son and her son's girlfriend who assist during non-service hours. Her friend is a personal aide.
Both Uniform Assessment System (UAS) State of New York were reviewed.
Tasking tool noted a total of 5 hours per day for a total of 35 hours a week. Subsequent tasking tool dated noted total of 6.5 hours per day for a total of 45.5 hours a week.
The patient needs additional services as documented by the UAS. Additional services of 6.5 hours a day increased from 4.5 hours a day. The medical status has regressed since previous evaluation and requires more care. There is a documented need of 6.5 hours a day of services. However, the patient does not have a documented need of 8.5 hours a day of services. In order for services to be approved for a total of 8.5 hours a day, a substantiated need must be noted, the specific documented need for 8.5 hours a day was not noted on the appeal, nursing assessment or other documentation provided.