Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis with associated mobility challenges
Treatment: Increase from 40 to 49 hours per week of home care/personal care [HHC]- level 2 personal care services, per 15 minutes

The insurer denied this requested increase in hours.
The determination is upheld.

The patient has a medical history of hypertension, diabetes, and osteoarthritis with associated mobility challenges. The patient was receiving 35 hours per week of level 2 personal care services and requested an increase in services. The plan approved an increase to 40 hours per week of services. An appeal was made by the patient to increase to 49 hours per week, and the health plan denied the appeal. No supporting documentation from any treating physicians regarding this request was provided.

A Uniform Assessment System (UAS) was performed. A prior assessment was available for comparison. Evaluation states that the patient was requesting increased services for assistance in cooking, cleaning, ambulation, and assistance with bathing and dressing. Evaluation of cognitive skills demonstrates that the patient has a memory problem as she is alert and oriented only to person; formal evaluation by a neurologist was recommended. Regarding the patient's functional status, she has total dependence for meal preparation and ordinary housework. She requires extensive assistance for managing finances, bathing, dressing lower body, walking, locomotion, toilet transfers, and toilet use. She requires maximal assistance for managing medications and shopping. She requires limited assistance for personal hygiene and dressing the upper body. Overall, the patient's self-sufficiency compared to the last assessment was noted to have deteriorated. The evaluation notes that the patient needs assistance for standing up, transferring, and ambulating. It is "very hard for her to be in a standing position for long periods of time and walk long distances. " The patient does have a daughter who helps on an unscheduled/as needed basis, who is responsible for managing medications in the times when the patient does not have assistance available. The patient has durable medical equipment of a rollator, shower chair, and grab bars to assist with mobility needs. The patient is continent of bladder and bowels. One fall was noted in the past 3 months. She exhibits unsteady gait. Comparison to prior assessment demonstrates a very similar level of functional status for activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). There is insufficient evidence that the requested increase to 49 hours per week of level 2 services is medically necessary. The patient's need is primarily driven by her decreased mobility (secondary to pain and osteoarthritis). Per the uniform assessment system tool, there have been no significant changes in functional status over the past year. There are no incontinence issues or skin breakdown. It is concerning that the patient had a fall within the past 3 months and is exhibiting symptoms of dementia, but level 2 services are not for the provision of safety and security. Additional information, provider records and letters, was requested, received and reviewed. The most recent office visit note from the patient's primary care provider was reviewed. The patient was noted to have suboptimal control of hypertension and diabetes, and modifications were made to her regimen. There is no documentation regarding a report of functional difficulties or challenges with completing ADLs/IADLs at home with current personal care services. The physical exam does not note any evidence of neurologic, musculoskeletal, psychiatric, or constitutional abnormalities.  A magnetic resonance imaging (MRI) scan was ordered for history of meningioma, vertigo, and headaches. There is no evidence of an indicated medical need that would support the request for additional service hours.