Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis (OA), dizziness and giddiness, high blood pressure, high cholesterol, difficulty walking, urinary incontinence, and history of medial meniscus tear of right knee
Treatment: Personal Care Services Level 2: 6 hours per day, 7 days per week; Total 42 hours per week
The insurer denied: Personal Care Services Level 2: 6 hours per day, 7 days per week; Total 42 hours per week
The denial is upheld.

The patient is an elderly female. The request is for an increase in Personal Care Services to 6 hours per day, 7 days per week (total 42 hours per week). She has been approved for 3 hours per day, for 5 days per week and 4 hours per day for 2 days per week (total 23 hours per week). The patient has medical diagnoses of osteoarthritis (OA), dizziness and giddiness, high blood pressure, high cholesterol, difficulty walking, urinary incontinence, and history of medial meniscus tear of right knee. She is status post left hip replacement. Three months ago, the Health Assessment Report indicates that the patient needed the following: 
1) Maximal assistance with meal preparation, shopping, and stairs; 
2) Extensive assistance with transportation; 
3) For the rest of the activities, she is independent or limited need for assistance. 
Two months ago, the health plan decided to deny the request for increased services as not medically necessary. "The request for Personal Care Services Level 2 was denied because you do not meet the criteria. This decision was based on: Personal care services are not authorized if the need for assistance can be safely met by using supplies like diapers, chux, commodes, walkers, or wheelchairs. Also, Managed Long Term Health Plans are not allowed by New York State regulations to provide an aide for safety and supervision alone."
The health plan further noted that the assessment from 3 months ago showed the patient needed limited assistance with bathing, dressing the upper body, and dressing the lower body as well as 
supervision with personal hygiene, walking, toilet transfer, and toilet use. It added that although there is a change in her physical status when compared to the assessment eight months ago, the level of care needed was unchanged.
The provider added that due to the above-listed conditions, the patient requires assistance with activities of daily living (ADL). The patient lives alone, and there is no one able to provide assistance to meet her need for assistance with activities of daily living.

The request for an increase in Personal Care Services to 6 hours per day, 7 days per week (total 42 hours per week) is not medically necessary.

The patient has been approved for 3 hours per day, for 5 days per week and 4 hours per day for 2 days per week (total 23 hours per week).
The review of records supports the plan decision to maintain the current level of home services. As noted above, the Health Assessment Report from three months ago indicates that the patient needed the following: 
1) Maximal assistance with meal preparation, shopping, and stairs; 
2) Extensive assistance with transportation; 
3) For the rest of the activities, she is independent or limited need for assistance. The review of records supports the plan decision to maintain the current level of home services. Therefore, the requested health service is not medically necessary.