Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 diabetes mellitus, hyperlipidemia, osteoarthritis, osteopenia, Parkinson's disease, primary hypothyroidism, venous insufficiency and hearing loss
Treatment: Home care / personal care HHC [home health care] - Level 2 personal care services / consumer directed personal assistance services of 40 hours per week
The insurer denied coverage for home care / personal care HHC - Level 2 personal care services / consumer directed personal assistance services of 40 hours per week
The denial is upheld

The patient is a female with a past medical history of adjustment disorder, type 2 diabetes mellitus, hyperlipidemia, osteoarthritis, osteopenia, Parkinson's disease, primary hypothyroidism, venous insufficiency and hearing loss. Per the office visit, the patient had a fall 3 months prior. She has declining activities of daily living and is at high risk for recurrent falls. Her doctor strongly recommended home attendant services for health maintenance. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her daughter were present on the call. She lives with her daughter on the 1st floor of a 3 bedroom apartment in a private home. 

Needs are: 

-	Maximal assistance for meal preparation, ordinary housework and shopping;
-	Extensive Assistance for managing finances, managing medications, phone use, transportation, bathing, dressing her upper and lower body and toilet transfer;
-	Limited assistance for personal hygiene, walking and locomotion;
-	Supervision/Independence for toilet use, bed mobility and eating.
-	Continence: The patient is frequently bladder incontinent but has complete bowel control. She wears pads for urinary incontinence.  

The patient uses an assistive device for locomotion indoors. 

The patient physician notes that she has declining Activities of Daily Living (ADLs) and is at risk for a fall.  This echoes his letter. He enclosed an article on impairments due to Parkinson's disease. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:

(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The issue is an increase in Personal Care Hours from 4 hours per day to 6 hours per day. A UAS and Tasking Tool were done. It has been noted that she has declined but specific changes are not documented. The doctor notes increased problems with ADLs and that she is a fall risk, but no specific increased needs are noted. The request for increased hours is not supported by the available record. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Home Care / Personal Care HHC - Level 2 Personal Care Services / Consumer Directed Personal Assistance Services of 40 hours per week is upheld. Medical Necessity is not substantiated.