Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major depressive disorder (MDD), unmanaged, Diabetes Mellitus, and Heart Failure

Treatment: increase in Personal Care Services, 5 hours per day, 7 days per week

The insurer denied coverage for increase in Personal Care Services, 5 hours per day, 7 days per week

The denial is upheld

 
This case involves an elderly female with a subject for review for the denial of coverage for increase in Personal Care Services, 5 hours per day, 7 days per week.

In this case, this is an elderly female who lives with her spouse, she has a history of Major depressive disorder (MDD), unmanaged, Diabetes Mellitus, and Heart Failure. Per the assessment, the member has increased lower back pain and weakness in legs relating to functional/ambulating decline. She also has increased stiffness, necessitating additional assistance. Member is alert and oriented to person, place, and time and is able to make her needs known and direct care. She can activate personal emergency response system (PERS) and was able to perform all steps in a multitask sequence. It was also noted that she uses an assistive device in walking. 

It was noted that the patient requires maximal assistance with meal preparation, totally dependent with ordinary housework, extensive assistance is needed for managing finances, managing medications, stairs, shopping, transportation, bathing, dressing the lower body, walking, and locomotion. Limited assistance is needed for phone use, personal hygiene, dressing the upper body, transfer to toilet, toilet use, bed mobility, and eating. The final recommendation according to the need of the member is a total of 28 hours for 7 days. 
The denial of the request for an increase in Personal Care Services, 5 hours per day, 7 days per week was reasonable due to the assessment using the Uniform Assessment System- New York Community Health Assessment and the Hours Evaluation for Paraprofessional Support (HELPS) tool.

The approved 5 hours a day, 6 days a week for a total of 30 hours is enough to meet the needs of the patient per the Hours Evaluation for Paraprofessional Support (HELPS) tool. The approved Personal Care Services can be used flexibly to help the member for meal preparation, ordinary housework, managing finances, managing medications, stairs, shopping, transportation, bathing, dressing the lower body, walking, and locomotion. In addition, for phone use, personal hygiene, dressing the upper body, transfer to toilet, toilet use, bed mobility, and eating. During a visit, physical therapy and shoulder injection was recommended by the physician to help with her pain, however, the patient declined. Physical Therapy may be able to help the patient with her pain and weakness. As such the denial for the request for and increase in Personal Care Services, 5 hours per day, 7 days per week is upheld and not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for increase in Personal Care Services, 5 hours per day, 7 days per week services is not substantiated.