Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbar strain and radiculopathy
Treatment: Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes Increase to 60 Hour(s) per Week
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 60 Hour(s) per Week.
The determination is upheld.

This is a female patient with a medical history notable for lumbar strain and radiculopathy. The patient is approved for 35 hours per week of consumer directed personal care services. The patient and her care team requested an increase to 60 hours per week, and this request was denied by the health plan.
The requesting physician provided a letter for this appeal. The letter states that the patient has type 2 diabetes mellitus, hypertension, asthma, hyperlipidemia, venous stasis, and osteoarthritis. There is no discussion regarding functional deficits or currently unmet personal care needs. A separate letter briefly states that the patient would "benefit from an additional 4 hours a week with their home care attendant," but does not discuss why these hours are being requested.
A Uniform Assessment System (UAS) was completed. The patient lives with her spouse and children in a home. She was alert and oriented and able to direct her own care. For her instrumental activities of daily living, she requires total dependence for meal preparation, housework, and shopping. She requires limited assistance for finances and medications. She requires extensive assistance for transportation. For her activities of daily living, she requires extensive assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires limited assistance for hygiene and dressing upper body. She is independent for bed mobility and eating. She had a knee replacement approximately 6 months prior and is still unable to air weight without pain or unsteadiness. She complains of pain in her bilateral knees which limit her ability to perform activities of daily living. She is occasionally incontinent of urine and uses briefs as needed. There was no pressure ulcer present. A task tool associated with the assessment recommended 34.42 hours per week to adjust the patient's personal care needs. Compared to a prior assessment, the patient showed a modest decline in functional status. At issue is the medical necessity of Home Care / Personal Care HHC (home health care)- Level 2 Personal Care Services, per 15 minutes Increase to 60 Hour(s) per Week.
The requested health service of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 60 Hour(s) per week has not been demonstrated to be medically necessary for this patient.
The patient requires some personal care assistance to help complete activities of daily living due to pain and instability in her legs. She is receiving personal care hours which are commensurate with the recommendation by the task tool. There is no discussion regarding which personal care needs, if any, are not currently being met by her allotment of hours. She has consumer directed hours and is able to disperse them throughout the day as needed to meet her needs. There is not clearly demonstrated evidence of medical necessity for the requested increase in personal care hours.