Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Home Health Care (70 hours per week) 
The insurer denied Home Care/Personal Care Home Health Care (HHC)- Level 2 Personal Care Services, per 15 minutes increase to 70 hours per week. 
The denial was upheld. 

The patient is a female with a past medical history significant for osteomyelitis of the right foot and ankle, diabetes mellitus type 2, asthma, methicillin-resistant staphylococcus aureus (MRSA), anemia, hyperlipidemia, gastroesophageal reflux disease, osteoarthritis, muscle weakness and difficulty walking. The patient was admitted to the hospital secondary to right foot and ankle osteomyelitis. Subsequent to the hospital, she went to nursing care and was discharged home. At the time of discharge, it was requested the patient have more personal care services. There is an appeal letter, noting the patient's medical problems as rationale for the appeal. She is currently authorized for 35 hours with services. Services were denied by her plan stating the appeal for increase in her personal care hours, 35 hours weekly to 70 hours weekly, was upheld. The patient has a past medical history of arthritis with no loss of motor function noted. The current personal care hours are currently 35 hours a week and it was not medically necessary to increase the hours to 70 hours a week. This was based on a follow-up Uniform Assessment System (UAS) State of New York tasking tool. Services have been denied based upon medical necessity. The patient is appealing this decision.

At issue is the medical necessity of Home Care/Personal Care Home Health Care (HHC)- Level 2 Personal Care Services, per 15 minutes increase to 70 hours per week.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Home Care/Personal Care HHC- Level 2 Personal Care Services, per 15 minutes increase to 70 hours per week is not medically necessary for this patient.

The patient is a female with multiple medical problems mainly related to diabetes mellitus with recent osteomyelitis requiring hospitalization and noting ambulatory dysfunction secondary to osteomyelitis. She showed no changes in her abilities to perform physical functions, bed mobility, bathing, personal hygiene, dressing upper and lower body, walking, eating, meal preparation, ordinary housework, and medication management. The patient was reassessed, and the authorized hours were adjusted accordingly. Personal care hours are currently authorized in amount, duration, and scope necessary to meet the patient's personal care needs. UAS State of New York tasking tool noted 34 hours a week of services. Previous UAS State of New York tasking tool noted 23 hours of services. The increase in services noted between the 2 evaluations were mainly for instrumental activities of daily living (IADLs). There was a slight increase in activities of daily living (ADLs). The amount of services noted are sufficient to meet the patient's needs. The increase in medical necessity from 23 hours a week to 34 hours week is taken into account by the assessment. The patient has service hours scheduled for 35 hours a week. On the appeal letter, it was noted that the patient has 35 hours a week of services and this leaves the patient without services on nights and weekends. The patient lives with her husband who is an informal caretaker, her daughter is the formal caretaker, and another daughter is available as an informal caretaker as noted on the documentation provided.

Therefore, the requested health service/treatment of Home Care/Personal Care HHC- Level 2 Personal Care Services, per 15 minutes increase to 70 hours per week is not medically necessary.