Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gait ataxia and mild cognitive impairment
Treatment: Personal care services 8-10 hours a day 7 days a week
The insurer denied the Personal care services 8-10 hours a day 7 days a week.
The determination is upheld.

The patient has a past medical history significant for benign prostatic hypertrophy, carpal tunnel, chronic obstructive pulmonary disease (COPD), constipation, hypertension, bowel incontinence, gastroesophageal reflux disease, history of falling, hyperlipidemia, hypothyroidism, insomnia, Paget's disease of the bone, history of cerebrovascular disease, urinary incontinence, diabetes mellitus and gait abnormality. He was noted to have mild cognitive impairment without the diagnosis of Alzheimer's disease; there is no medical treatment noted for his cognitive impairment. The plan denied services stating on the last assessment that the patient needed help preparing meals, housekeeping, laundry, shopping, bathing and dressing lower body. The patient needed limited help with personal hygiene, dressing upper body and toileting. He is independent with moving in bed and with eating. He has intermittent incontinence of bladder and bowels. The plan provides incontinence supplies to keep the patient dry. He is able to use a cane indoors and a walker outdoors. Time was not being provided for safety supervision, companionship or when there were no tasks done.

This review is for the medical necessity of personal care services 8-10 hours a day 7 days a week. The patient currently receives services for a total of 48 hours per week.

The requested health service is not medically necessary for this patient. This is a patient with the medical history of benign prostatic hypertrophy, carpal tunnel, chronic obstructive pulmonary disease, constipation, hypertension, bowel incontinence, gastroesophageal reflux disease, history of falling, hyperlipidemia, hypothyroidism, insomnia, Paget's disease of the bone, history of cerebrovascular disease, urinary incontinence, diabetes mellitus and gait abnormality.

A Uniform Assessment System (UAS) State of New York and a HELPS (Hours Evaluation for Paraprofessional Support Tool) assessment was reviewed and recommended a total of 33 hours a week of services. The tasking tool noted the patient required 33 hours services over 7 days and was authorized for 48 hours. The physician progress statement was reviewed.

Based upon the information provided, the time allotted for the services is adequate to meet the patient's needs especially with scheduled tasks as noted. The one issue brought up specifically in the appeal was in regards to unscheduled tasks, specifically incontinence. Time for safety monitoring and supervision/companionship is typically not considered medically necessary. The question is whether the patient needs an additional 37 hours a week to meet these needs. The patient's needs were noted to be 33 hours a week. The patient has been approved for 48 hours a week, which is 15 hours over his expected needs. Regarding whether the patient needs an additional 37 hours a week to manage incontinence when supplies are provided, there were no specific medical needs noted in the physician statement, the appeal, or other documentation which would necessitate more frequent changing. Incontinence is an unscheduled event, so additional hours cannot manage that condition any better, however, adjusting the timing of the services may be more appropriate. Additional services are not medically necessary.