Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polyosteoarthritis, weakness, visual disturbance
pain, polyneuropathies, insomnia, gastroesophageal reflux disease (GERD).
Treatment: Home Care / Personal Care Home Health Care (HHC) - Level II Personal Care Services, per 15 minutes, from 35 Hours To 56 Hours Per Week.
The insurer denied the Home Care / Personal Care Home Health Care (HHC) - Level II Personal Care Services, per 15 minutes, from 35 Hours To 56 Hours Per Week.
The denial is upheld. 

This patient is a male with diagnoses including, polyosteoarthritis, weakness, visual disturbance pain, polyneuropathies, insomnia, gastroesophageal reflux disease (GERD), dizziness and giddiness, dry eye syndrome, and hyperlipidemia.  He lives with relatives in a two bedroom.  He is appealing the requested Level II personal care services (PCS) at 56 hours per week.  He has been approved for 35 hours per week.  

Assessment performed shows cognition is modified independent and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing medications; extensive assistance with phone use, bathing, dressing and toileting; limited assistance with personal hygiene, walking, and locomotion; and independent with eating.  No incontinence.  Durable medical equipment (DME) includes shower chair and grab bars. Family members assist with finances and reminder to take medications.  Occasionally, the patient is incontinent of bladder.  The provider appealed to increase to 56 personal care service (PCS) hours per week.

No, the proposed treatment is not medically necessary.
Medically necessary services are those which are:
1)safe. 2)effective. 3)generally accepted national standard of medical practice. 4) not provided primarily for convenience of the patient or the practitioner. 5)the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is not medically necessary because it is not consistent with generally accepted national standard of medical practice.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient was approved for 35 personal care service (PCS) hours based on assessment performed.  His functional status is limited due to arthritis and pain.  This assessment shows the patient needs assistance with meal preparation, housework, shopping, managing medications, phone use, bathing, dressing toileting personal hygiene, walking, and locomotion.  The patient has a shower chair and grab bars.  The patient is appealing this number of hours approved based on need for assistance with activities of daily living (ADLs) that are already accounted for in the assessment.  His doctor is recommending additional hours but has not provided a statement or additional information supporting additional hours.  The approved 35 hours per week is sufficient to provide assistance with activities of daily living (ADLs) and personal care as noted above. Personal care services (PCS) are not indicated for management of chronic medical conditions.  Personal care services (PCS) are not indicated when there are no tasks being performed.  The information provided does not support the proposed increase in personal care services (PCS) to a total 56 hours per week.