Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Visual impairment, obesity, back pain, diabetes, hypertension, functional urinary incontinence, and lymphedema
Treatment: Increase Personal Care Assistance Services to 77 Hours per Week
The insurer denied Increase Personal Care Assistance Services to 77 Hours per Week.
The denial is upheld.

The patient is an elderly female with multiple medical conditions, including visual impairment, obesity, back pain, diabetes, hypertension, functional urinary incontinence, and lymphedema. The request is for an increase in Personal Care Assistance to a total of 77 hours per week from the currently approved 8 hours per day, 7 days per week (56 hours per week total). The plan denied the request for increased hours last month and subsequently upheld their decision recently, with the rationale noting that "your personal care tasks can still be done in the time that has been provided during the current hours you receive within your plan of care." In an appeal letter, the patient's physician notes that the current hours are insufficient, as the patient is blind and weak from recent COVID. The provider notes that the patient requires assistance with transfers and ambulation. The provider notes that the patient is at high risk for falls when left unattended and is incontinent. The letter further notes that the patient requires help with shopping, food preparation, bathing, dressing, laundry, and housekeeping. The patient needs an escort for doctor appointments and medication reminders.  According to a nursing assessment completed last year, the patient requires maximal assistance with meal preparation, shopping, and housework. She requires extensive assistance with medication management, bathing, dressing upper body, walking, toilet transfer and use. She requires limited assistance with personal hygiene, bed mobility, and eating.

The requested health service is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. The request is for an increase in Personal Care Assistance to a total of 77 hours per week from the currently approved 8 hours per day, 7 days per week (56 hours per week total). The submitted documentation does not reflect which activities of daily living cannot be completed within the currently approved 56 hours per week. The provider notes that the patient needs assistance with ambulation, shopping, food preparation, bathing, dressing, laundry, and housekeeping. However, as noted in the plan denial rationale, time for these activities of daily living have already been accounted for in the hours approved by the plan. A tasking tool completed last month reflects that the patient requires 39.51 hours per week to accomplish their activities of daily living. The appeal information does not specifically show which activities would require an additional 21 hours of care beyond the currently approved hours. The provider note alludes to the need for additional supervision due to the patient's high risk of falls, indicating that additional hours beyond those currently supplied by the plan would be for safety only. However, personal care services are not covered for supervision and safety concerns, per New York State Guidelines. Based on the available information, the plan's initial denial rationale is appropriate. Thus, the increase in 77 hours per week from the currently approved 8 hours per day, 7 days per week (56 hours per week total) is not medically necessary.