Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Home Health Care. 
The insurer denied increase in consumer directed personal assistance services (CDPAS) from 56 hours a week to 140 hours a week. 
The denial is upheld.

The patient is a male with past medical history significant for diabetes, hypertension, backache, end-stage renal disease and pain in right and left shoulder. The patient is currently dialysis dependent 3 times a week.
The subject under review is the medical necessity for the increase in Consumer Directed Personal Assistance Services (CDPAS) from 56 hours a week to 140 hours a week. The increase in services was denied based on lack of medical necessity.  

The health plan's determination is upheld.

the requested health service of increase in consumer directed personal assistance services from 56 hours to 140 hours per week is not medically necessary for this patient.
Increase in services were denied by the health plan based on the patient not meeting criteria. "This self-directing member's function has declined, now requiring maximum or extensive assistance with bathing, dressing lower body, bed mobility, toileting, and locomotion. His activities of daily living status has declined compared to 90 days ago, or since last assessment if less than 90 days ago. He is now frail as evidenced by noting severe fatigue, walking less than a city block, needing assistance to walk up a flight of stairs and having more than five illnesses. He has fallen and been hospitalized in the past 60 days. His medical diagnoses and medications are moderately changed consistent with his multiple chronic medical problems and hospitalization. This member is currently receiving 56 hours of care per week. Given his decline in function it is medically necessary to continue to provide this member with 56 hours a care per week, which is 14% more care hours than his tasking tool estimates (49 hours)."
An increase services were requested by the patient and his physician due to the patient's worsening shoulder pain and generalized medical decline.
Uniform Assessment System (UAS) State of New York was reviewed. The tasking tool noted need for 49 hours week, with more hours noted for toilet use, locomotion, and personal hygiene. Prior UAS State of New York was reviewed. Tasking tool noted need for 35.5 hours a week.
The patient is an elderly male with multiple medical problems with declining physical function secondary to his underlying conditions. He lives with his family in a private house. His medical issues include problems with mobility, gait transfers and use of his upper extremities secondary to osteoarthritis. Nursing evaluation as noted by UAS has shown a decline between the two evaluations mainly for personal care hygiene issues such as toilet use, bathing, and locomotion.
While the patient's physical health has declined, the number of hours required has been accounted for in the evaluations. There is no noted medical reason in the information provided stating that the hours required for the patient's activities of daily living (ADLs) and instrumental activities of daily living (IADLs) could not be completed in the allotted 56 hours a week.