Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End-stage-renal disease, human immunodeficiency virus-associated nephropathy (HIVAN), hypertension, sickle cell trait, cerebral vascular accident (CVA), seizure disorder, diabetes 
mellitus, diabetic ketoacidosis, status post kidney transplant
Treatment: Increase Personal Care Services, 9 Hours per Day, 7 Days per Week, a Total of 63 Hours
The insurer denied: Increase Personal Care Services, 9 Hours per Day, 7 Days per Week, a Total of 63 Hours
The denial is upheld.

The patient is an adult female with history of general debility. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 46 hours per week (7 hours per day times 4 days, plus 6 hours per day times 3 days) based on Uniform Assessment System (UAS) of 4 months ago to 63 hours per week (9 hours per day, 7 days per week) based on Uniform Assessment System (UAS) of 2 months ago. The health plan denied the request because the patient has some impairments for which she could continue physical therapy and occupational therapy once a week, that she lives with the son in an apartment on the third floor, that she has a walker and cane to help with ambulation, that the plan does not provide time for companionship but rather for personal care hours, and that she attends dialysis three times a week for which the plan provides transportation during which time she has no need for an aide.
The additional hours requested are because of the patient's chronic medical conditions, and to help with preparing meals, housekeeping, laundry, shopping, dressing, bathing, transferring, eating, toileting, personal hygiene, etc. A review of the records showed that patient has multiple chronic medical conditions including end-stage-renal disease, human immunodeficiency virus-associated nephropathy (HIVAN), hypertension, sickle cell trait, cerebral vascular accident (CVA), seizure disorder, diabetes mellitus, diabetic ketoacidosis, status post kidney transplant, etc.
Uniform Assessment System-New York (UAS-NY) evaluation of 2 months ago showed that cognitively the patient is modified independent; she requires extensive assistance with personal hygiene, upper body dressing, locomotion, toilet transfer, toileting; she requires maximum assistance with meal preparation, ordinary housework, shopping, bathing, lower body dressing; and she requires limited assistance with bed mobility, eating, etc. Her family support is very good as she lives with her son.

The requested health service is not medically necessary.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 46 hours per week (7 hours per day times 4 days, plus 6 hours per day times 3 days) based on Uniform Assessment System (UAS) of 4 months ago to 63 hours per week (9 hours per day, 7 days per week) based on Uniform Assessment System of 2 months ago is not medically necessary. The most recent Uniform Assessment System of 2 months ago showed that cognitively the patient is modified independent; she requires extensive assistance with personal hygiene, upper body dressing, locomotion, toilet transfer, toileting; she requires maximum assistance with meal preparation, ordinary housework, shopping, bathing, lower body dressing; and she requires limited assistance with bed mobility, eating, etc. Her family support is very good as she lives with the son. The reasons for denial by the health plan as stated in the clinical information above, do align with the patient's disability features as stated in the Uniform Assessment System of 2 months ago, as stated above. The patient spends a few hours three days a week in dialysis for which the requested extra hours cannot be justified as medically necessary. Also, there is no record that her condition has deteriorated to a level of requiring more assistance. Therefore the 63 hours per week (9 hours per day, 7 days per week) based on Uniform Assessment System of 2 months ago requested should not be approved.